=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851186258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAKAILYN GRACE SCHOONOVER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2025
-----------------------------------------------------
Last Update Date | 04/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1023 NEW MOODY LN STE 102
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40031-9183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-222-0598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1704 GRAND VILLA DR
-----------------------------------------------------
City | LA GRANGE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40031-8956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-758-6119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | TC031
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | TC031
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------