Provider Demographics
NPI:1609216746
Name:LACROIX, KELLY JUSTINE
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JUSTINE
Last Name:LACROIX
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:JUSTINE
Other - Last Name:MCPHERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3968 W 146TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-4321
Mailing Address - Country:US
Mailing Address - Phone:216-970-0316
Mailing Address - Fax:
Practice Address - Street 1:3968 W 146TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-4321
Practice Address - Country:US
Practice Address - Phone:216-970-0316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400521390706376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide