Healthcare Provider Details

I. General information

NPI: 1497179477
Provider Name (Legal Business Name): RAE EAVES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 NICHOLASVILLE RD STE 106
LEXINGTON KY
40503-2517
US

IV. Provider business mailing address

3198 CUSTER DR STE 100
LEXINGTON KY
40517-4074
US

V. Phone/Fax

Practice location:
  • Phone: 859-278-5926
  • Fax: 859-276-3189
Mailing address:
  • Phone: 859-231-6996
  • Fax: 859-255-4104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3008431
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3008431
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: