Provider Demographics
NPI:1922199470
Name:NILES, VANESSA (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:NILES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PIEDMONT AVE NE
Mailing Address - Street 2:STE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-2544
Mailing Address - Country:US
Mailing Address - Phone:404-756-1403
Mailing Address - Fax:404-756-5252
Practice Address - Street 1:1800 HOWELL MILL RD
Practice Address - Street 2:STE 275
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2508
Practice Address - Country:US
Practice Address - Phone:404-756-1400
Practice Address - Fax:404-756-5252
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13889207V00000X
GA064619207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC138899Medicaid
GA00312722ICMedicaid
GA00312722ICMedicaid
SCD741606811Medicare ID - Type Unspecified