Healthcare Provider Details

I. General information

NPI: 1255328084
Provider Name (Legal Business Name): LORRAINE A RUST-KILLEEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9905 SHELBYVILLE RD
LOUISVILLE KY
40223-2907
US

IV. Provider business mailing address

9905 SHELBYVILLE RD
LOUISVILLE KY
40223-2907
US

V. Phone/Fax

Practice location:
  • Phone: 502-425-5166
  • Fax: 502-327-0526
Mailing address:
  • Phone: 502-425-5166
  • Fax: 502-327-0526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25573
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25573
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: