Provider Demographics
NPI:1053383257
Name:NILLES, JOAN M (MD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:NILLES
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 1:24 N 9TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-3909
Mailing Address - Country:US
Mailing Address - Phone:515-574-6890
Mailing Address - Fax:
Practice Address - Street 1:2015 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-3000
Practice Address - Country:US
Practice Address - Phone:712-732-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI3388Medicare PIN
E05030Medicare UPIN