Provider Demographics
NPI:1104636679
Name:GRADY, MIRIAM AMY
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:AMY
Last Name:GRADY
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 1:841 SORIN ST APT 2H
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:841 SORIN ST APT 2H
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2066
Practice Address - Country:US
Practice Address - Phone:402-216-9739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program