Basic Information
| Provider Information | |||||||||
| NPI: | 1265819064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NILLES | ||||||||
| FirstName: | GUINEVERE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6610 MUTUAL DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468254236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848830 | ||||||||
| FaxNumber: | 2604831911 | ||||||||
| Practice Location | |||||||||
| Address1: | 7910 W JEFFERSON BLVD STE 108 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604848830 | ||||||||
| FaxNumber: | 2604831911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2015 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 10001910A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.