Healthcare Provider Details

I. General information

NPI: 1548923691
Provider Name (Legal Business Name): AUTUMN COBBS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14910 PERRIS BLVD STE B
MORENO VALLEY CA
92553-7181
US

IV. Provider business mailing address

14910 PERRIS BLVD STE B
MORENO VALLEY CA
92553-7181
US

V. Phone/Fax

Practice location:
  • Phone: 909-654-6235
  • Fax:
Mailing address:
  • Phone: 909-654-6235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95018163
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: