Provider Demographics
NPI:1518198365
Name:NILES, GEORGIA ANN (ARNP)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:ANN
Last Name:NILES
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 1:850 BARRET AVE
Mailing Address - Street 2:SUITE #301
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1745
Mailing Address - Country:US
Mailing Address - Phone:502-574-6699
Mailing Address - Fax:502-574-5922
Practice Address - Street 1:850 BARRET AVE
Practice Address - Street 2:SUITE #301
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1745
Practice Address - Country:US
Practice Address - Phone:502-574-6699
Practice Address - Fax:502-574-5922
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4328P363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78013091Medicaid
KY78013091Medicaid