Provider Demographics
NPI:1588072300
Name:MILLER, GRACE DOMINIQUE (RN)
Entity type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:DOMINIQUE
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 JEFFERSON AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-7331
Mailing Address - Country:US
Mailing Address - Phone:516-939-3005
Mailing Address - Fax:
Practice Address - Street 1:371 E 51ST ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3507
Practice Address - Country:US
Practice Address - Phone:917-651-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY761864163WH0200X, 163WM0705X, 163WA0400X
NY314147164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No164W00000XNursing Service ProvidersLicensed Practical Nurse