Healthcare Provider Details

I. General information

NPI: 1245124965
Provider Name (Legal Business Name): MAKENA GRACE DILLASHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 6TH AVE S # M855C
BIRMINGHAM AL
35233-1932
US

IV. Provider business mailing address

374 COUNTY ROAD 1651
CULLMAN AL
35058-7832
US

V. Phone/Fax

Practice location:
  • Phone: 205-934-6256
  • Fax:
Mailing address:
  • Phone: 256-347-6861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-158332
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1-158332
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: