Provider Demographics
NPI:1275224594
Name:MIRACLE, MAYLEE GRACE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MAYLEE
Middle Name:GRACE
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:MAYLEE
Other - Middle Name:G
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 5TH ST STE 310
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-5919
Mailing Address - Country:US
Mailing Address - Phone:423-573-6836
Mailing Address - Fax:
Practice Address - Street 1:100 5TH ST STE 310
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-5919
Practice Address - Country:US
Practice Address - Phone:423-573-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34099363LP0808X
TN0000245367163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse