Provider Demographics
NPI:1972736908
Name:NILES, KATHERINE FOUNTAIN (PA)
Entity type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:FOUNTAIN
Last Name:NILES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:KATHERINE
Other - Middle Name:ELIZABETH
Other - Last Name:FOUNTAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 E ST NW
Mailing Address - Street 2:US DEPT OF STATE M/MED/QI, SA-1
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20522-0102
Mailing Address - Country:US
Mailing Address - Phone:202-663-2453
Mailing Address - Fax:202-663-3247
Practice Address - Street 1:US DEPT OF STATE 2401 E ST NW
Practice Address - Street 2:M/MED/QI, SA-1
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20522-0001
Practice Address - Country:US
Practice Address - Phone:202-663-2453
Practice Address - Fax:202-663-3247
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002401363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical