MEDICARE: AT HOME GRACEFULLY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1871432153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AT HOME GRACEFULLY LLC

Provider Business Mailing Address
First Line	:	1107 PAYNE ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-2313
Country	:	US
Telephone Number	:	502-509-6233
Fax Number	:

Provider Business Practice Location Address
First Line	:	1107 PAYNE ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-2313
Country	:	US
Telephone Number	:	502-509-6233
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TALISHA L OUTLAW
Credential	:
Telephone Number	:	502-509-6233

Provider Enumeration Date	:	03/25/2026
Last Update Date	:	03/26/2026

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Directions to “AT HOME GRACEFULLY LLC ” Practice Location

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