Provider Demographics
NPI:1942920327
Name:GRAY, MAKAHLA
Entity Type:Individual
Prefix:
First Name:MAKAHLA
Middle Name:
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:942 N 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-1504
Mailing Address - Country:US
Mailing Address - Phone:402-510-6066
Mailing Address - Fax:
Practice Address - Street 1:942 N 28TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-1504
Practice Address - Country:US
Practice Address - Phone:402-510-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
NE372500000X, 376J00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE81400768Medicaid