Provider Demographics
NPI:1154940971
Name:NILES, RAVEN N (ARNP)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:N
Last Name:NILES
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-1737
Mailing Address - Country:US
Mailing Address - Phone:319-330-3712
Mailing Address - Fax:
Practice Address - Street 1:732 13TH AVE
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-1737
Practice Address - Country:US
Practice Address - Phone:319-330-3712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-12
Last Update Date:2020-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG158269363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health