MEDICARE: MRS. KELLY JUSTINE LACROIX

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	400521390706	OH

General Provider Information

NPI Number	:	1609216746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY JUSTINE LACROIX

Provider Business Mailing Address
First Line	:	3968 W 146TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-4321
Country	:	US
Telephone Number	:	216-970-0316
Fax Number	:

Provider Business Practice Location Address
First Line	:	3968 W 146TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-4321
Country	:	US
Telephone Number	:	216-970-0316
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2013
Last Update Date	:	07/03/2013

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Directions to “ MRS. KELLY JUSTINE LACROIX ” Practice Location

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