Healthcare Provider Details

I. General information

NPI: 1093518441
Provider Name (Legal Business Name): MACKENZIE NICOLE GRAEBE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 FOUNTAIN CT
LEXINGTON KY
40509-2792
US

IV. Provider business mailing address

245 FOUNTAIN CT
LEXINGTON KY
40509-2792
US

V. Phone/Fax

Practice location:
  • Phone: 858-323-6021
  • Fax: 859-323-1670
Mailing address:
  • Phone: 858-323-6021
  • Fax: 859-323-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR7448
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: