Provider Demographics
NPI:1023502234
Name:NILES, EMILY (DPM)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:
Last Name:NILES
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:1276 12TH ST N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3626
Mailing Address - Country:US
Mailing Address - Phone:850-324-8965
Mailing Address - Fax:
Practice Address - Street 1:3636 UNIVERSITY BLVD S BLDG C
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4250
Practice Address - Country:US
Practice Address - Phone:904-731-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPR552213E00000X
FLPO4220213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist