Provider Demographics
NPI:1508987462
Name:NILLES, MARY C (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:NILLES
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21811 W 52ND ST N
Mailing Address - Street 2:
Mailing Address - City:ANDALE
Mailing Address - State:KS
Mailing Address - Zip Code:67001-9707
Mailing Address - Country:US
Mailing Address - Phone:316-796-1155
Mailing Address - Fax:
Practice Address - Street 1:9300 E 29TH ST N
Practice Address - Street 2:STE 102
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2182
Practice Address - Country:US
Practice Address - Phone:316-687-2112
Practice Address - Fax:316-687-1260
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45918363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily