Provider Demographics
NPI:1316328560
Name:LACROIX, CARLY AGNES (DO)
Entity type:Individual
Prefix:DR
First Name:CARLY
Middle Name:AGNES
Last Name:LACROIX
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:110 E ROUTT AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2117
Mailing Address - Country:US
Mailing Address - Phone:719-543-8711
Mailing Address - Fax:719-543-0171
Practice Address - Street 1:300 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2006
Practice Address - Country:US
Practice Address - Phone:719-543-8711
Practice Address - Fax:719-543-0171
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR.0059223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty