Healthcare Provider Details

I. General information

NPI: 1659286748
Provider Name (Legal Business Name): MADELYN GRACE MASTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 ROSE STREET
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

69 PAYTEN LN
LONDON KY
40744-7551
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-6161
  • Fax:
Mailing address:
  • Phone: 606-312-6086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: