Provider Demographics
NPI:1750820932
Name:JILES, PROVIESS
Entity Type:Individual
Prefix:
First Name:PROVIESS
Middle Name:
Last Name:JILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2343 LAKE WESTON DR
Mailing Address - Street 2:1516
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-4492
Mailing Address - Country:US
Mailing Address - Phone:401-327-1354
Mailing Address - Fax:
Practice Address - Street 1:2343 LAKE WESTON DR
Practice Address - Street 2:1516
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-4492
Practice Address - Country:US
Practice Address - Phone:401-327-1354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376J00000X, 372500000X, 372600000X, 374U00000X
FL376K00000X376K00000X
FL172A0000X172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
No172A00000XOther Service ProvidersDriver
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion