Provider Demographics
NPI:1497915839
Name:RABORN, LAURIE CHARLENE (DO)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:CHARLENE
Last Name:RABORN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N 300 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-1215
Mailing Address - Country:US
Mailing Address - Phone:801-463-7415
Mailing Address - Fax:
Practice Address - Street 1:49 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3049
Practice Address - Country:US
Practice Address - Phone:404-616-6673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT7866874-1204207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program