Provider Demographics
NPI:1801343942
Name:LA CROIX, GWENDOLYN K (PMHNP-BC, RN)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:K
Last Name:LA CROIX
Suffix:
Gender:F
Credentials:PMHNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-1353
Mailing Address - Country:US
Mailing Address - Phone:313-999-4499
Mailing Address - Fax:
Practice Address - Street 1:410 NORTH ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1354
Practice Address - Country:US
Practice Address - Phone:313-590-9296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285632363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health