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General NPI Number Information
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NPI Number | 1558923326
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Entity Type | Individual
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Provider Name | MACKENZIE GRAYE MCMILLIN PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/02/2019
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Last Update Date | 09/26/2025
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Provider Practice Location Address
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Address Line | 33 SEWALL ST
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City | PORTLAND
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State | ME
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Zip | 04102-2603
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Country | US
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Telephone | 72-828-2100
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Fax |
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Provider Business Mailing Address
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Address Line | 33 SEWALL ST
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City | PORTLAND
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State | ME
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Zip | 04102-2603
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Country | US
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Telephone | 207-828-2101
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Fax | 207-553-7166
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA1918
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PAN1918
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License Number State | ME
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