Healthcare Provider Details

I. General information

NPI: 1275224594
Provider Name (Legal Business Name): MAYLEE GRACE MIRACLE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAYLEE G HAYNES

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 BLUFF CITY HWY STE 3
BRISTOL TN
37620-4637
US

IV. Provider business mailing address

926 W OAKLAND AVE STE 202
JOHNSON CITY TN
37604-1445
US

V. Phone/Fax

Practice location:
  • Phone: 423-534-9195
  • Fax:
Mailing address:
  • Phone: 423-850-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024192489
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number34099
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0000245367
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: