Individual ProviderVivian Lee RakestrawNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersPractice Address215 Central Ave Ste 100, Louisville, KY 40208-1450(502) 852-2822(502) 217-8221PECOS EnrollmentBased on the most recent information from CMS, provider Vivian Lee Rakestraw does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 2 days ago.Profile DetailsProvider ID1316975063Provider TypeIndividualFull NameRakestraw, Vivian LeeGenderFemaleSole ProprietorNoEnumeration Date6/30/2006Last Updated8/17/2010Contact InformationPractice LocationPractice Address215 Central Ave Ste 100, Louisville, KY 40208-1450Phone(502) 852-2822Fax(502) 852-2819Mailing LocationMailing Address501 E Broadway, Suite 290, Louisville, KY 40202-1785Phone(502) 217-8221Fax(502) 217-5056Provider TaxonomiesCodeDescriptionLicenseCode363LF0000XPrimaryDescriptionNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersLicense4778PKentuckyProvider IdentifiersIDDescriptionIssuerID200981170DescriptionMedicaidIssuerUnlistedIndianaID4778PDescriptionOtherIssuerARNP LICENSEKentuckyID1025939DescriptionOtherIssuerRN LICENSEKentuckyID7100021840DescriptionMedicaidIssuerUnlistedKentucky