Provider Demographics
NPI:1326239930
Name:RABAUT, KRISTEN LYNNE (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:LYNNE
Last Name:RABAUT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12911 SHELBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1613
Mailing Address - Country:US
Mailing Address - Phone:502-254-1100
Mailing Address - Fax:502-254-7634
Practice Address - Street 1:12911 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1613
Practice Address - Country:US
Practice Address - Phone:502-254-1100
Practice Address - Fax:502-254-7634
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003459152W00000X
KY1705DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100042720Medicaid
000000567489OtherANTHEM BCBS
KYP00683702OtherRAILROAD MEDICARE
KY5419240002Medicare NSC
KY7100042720Medicaid
KY5419240007Medicare NSC
KY5419240004Medicare NSC
KY5419240005Medicare NSC