Provider Demographics
NPI:1265819064
Name:NILLES, GUINEVERE M (PA)
Entity Type:Individual
Prefix:
First Name:GUINEVERE
Middle Name:M
Last Name:NILLES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6610 MUTUAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-4236
Mailing Address - Country:US
Mailing Address - Phone:260-484-8830
Mailing Address - Fax:260-483-1911
Practice Address - Street 1:7910 W JEFFERSON BLVD STE 108
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-484-8830
Practice Address - Fax:260-483-1911
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
IN10001910A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant