Healthcare Provider Details

I. General information

NPI: 1396675138
Provider Name (Legal Business Name): GRACE MACKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

3068 RANCHFIELD DR
BEAVERCREEK OH
45432-2611
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-8000
  • Fax:
Mailing address:
  • Phone: 937-430-5455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.0021545
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: