Healthcare Provider Details

I. General information

NPI: 1053383257
Provider Name (Legal Business Name): JOAN M NILLES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 W 5TH ST
STORM LAKE IA
50588-3000
US

IV. Provider business mailing address

24 N 9TH ST SUITE A
FORT DODGE IA
50501-3909
US

V. Phone/Fax

Practice location:
  • Phone: 712-732-6650
  • Fax:
Mailing address:
  • Phone: 515-574-6890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23548
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: