Provider Demographics
NPI:1033668967
Name:NILES, CHANTELLE (PA)
Entity Type:Individual
Prefix:
First Name:CHANTELLE
Middle Name:
Last Name:NILES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:KS
Mailing Address - Zip Code:67467
Mailing Address - Country:US
Mailing Address - Phone:785-392-2144
Mailing Address - Fax:785-392-3231
Practice Address - Street 1:830 ELM ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:KS
Practice Address - Zip Code:67467
Practice Address - Country:US
Practice Address - Phone:785-392-2144
Practice Address - Fax:785-392-3231
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01944363A00000X, 363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201143430BMedicaid