Provider Demographics
NPI:1770160756
Name:NILES, JESSICA DIANNE (FNP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DIANNE
Last Name:NILES
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 S OCEAN BLVD APT 804
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-6999
Mailing Address - Country:US
Mailing Address - Phone:954-798-1494
Mailing Address - Fax:
Practice Address - Street 1:1500 NW 10TH AVE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1312
Practice Address - Country:US
Practice Address - Phone:561-391-2708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM59519363LF0000X
FL11015206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty