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:
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 1:926 W OAKLAND AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-1445
Mailing Address - Country:US
Mailing Address - Phone:423-850-1150
Mailing Address - Fax:
Practice Address - Street 1:739 BLUFF CITY HWY STE 3
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-4637
Practice Address - Country:US
Practice Address - Phone:423-534-9195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000245367163W00000X
VA0024192489363LP0808X
TN34099363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse