Basic Information
| Provider Information | |||||||||
| NPI: | 1922199470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NILES | ||||||||
| FirstName: | VANESSA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 PIEDMONT AVE NE | ||||||||
| Address2: | STE 700 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303032544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561403 | ||||||||
| FaxNumber: | 4047565252 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 HOWELL MILL RD | ||||||||
| Address2: | STE 275 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303182508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047561400 | ||||||||
| FaxNumber: | 4047565252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 03/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 13889 | SC | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 064619 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 138899 | 05 | SC | MEDICAID | 00312722IC | 05 | GA | MEDICAID |