Provider Demographics
NPI:1316975063
Name:RAKESTRAW, VIVIAN LEE
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:LEE
Last Name:RAKESTRAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:LEE
Other - Last Name:LEFFLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:501 E BROADWAY
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1785
Mailing Address - Country:US
Mailing Address - Phone:502-217-8221
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:215 CENTRAL AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1450
Practice Address - Country:US
Practice Address - Phone:502-852-2822
Practice Address - Fax:502-852-2819
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4778P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200981170Medicaid
KY4778POtherARNP LICENSE
KY1025939OtherRN LICENSE
KY7100021840Medicaid
KY01174020Medicare PIN