Healthcare Provider Details

I. General information

NPI: 1508987462
Provider Name (Legal Business Name): MARY C NILLES ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 E 29TH ST N STE 102
WICHITA KS
67226-2182
US

IV. Provider business mailing address

21811 W 52ND ST N
ANDALE KS
67001-9707
US

V. Phone/Fax

Practice location:
  • Phone: 316-687-2112
  • Fax: 316-687-1260
Mailing address:
  • Phone: 316-796-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number45918
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: