Provider Demographics
NPI:1003484841
Name:NILES, MICHELLE L
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:NILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:GRIMSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-2016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 PHILLIPS ST
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-2016
Practice Address - Country:US
Practice Address - Phone:315-764-8076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist