Provider Demographics
NPI:1043792690
Name:RUTTER, KAITLYN NICOLE (RBT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:NICOLE
Last Name:RUTTER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 BROADWAY ST APT 5
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-1763
Mailing Address - Country:US
Mailing Address - Phone:502-644-9299
Mailing Address - Fax:
Practice Address - Street 1:650 W LINCOLN TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-2681
Practice Address - Country:US
Practice Address - Phone:270-352-1132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRBT-18-63620374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYRBT-18-63620OtherBACB