Provider Demographics
NPI:1447568308
Name:LACROIX, CHARLEANE CHANTELL (CNM)
Entity Type:Individual
Prefix:MS
First Name:CHARLEANE
Middle Name:CHANTELL
Last Name:LACROIX
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16355 SAYRES AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-3928
Mailing Address - Country:US
Mailing Address - Phone:718-344-0297
Mailing Address - Fax:
Practice Address - Street 1:1 VAN WYCK PLZ
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2826
Practice Address - Country:US
Practice Address - Phone:718-206-6290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001401367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid