Basic Information
| Provider Information | |||||||||
| NPI: | 1316975063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAKESTRAW | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | LEE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEFFLER | ||||||||
| OtherFirstName: | VIVIAN | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022178221 | ||||||||
| FaxNumber: | 5022175056 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 CENTRAL AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402081450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028522822 | ||||||||
| FaxNumber: | 5028522819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 08/17/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4778P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200981170 | 05 | IN | MEDICAID | 4778P | 01 | KY | ARNP LICENSE | OTHER | 1025939 | 01 | KY | RN LICENSE | OTHER | 7100021840 | 05 | KY | MEDICAID |