Provider Demographics
NPI:1982848024
Name:LACROIX, BERNITA R (R D)
Entity Type:Individual
Prefix:
First Name:BERNITA
Middle Name:R
Last Name:LACROIX
Suffix:
Gender:F
Credentials:R D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3314 SERENITY LN SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-1102
Mailing Address - Country:US
Mailing Address - Phone:360-493-1884
Mailing Address - Fax:
Practice Address - Street 1:4820 SHE NAH NUM DR SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98513-9105
Practice Address - Country:US
Practice Address - Phone:360-459-5312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 00000907133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered