Healthcare Provider Details

I. General information

NPI: 1568843316
Provider Name (Legal Business Name): SUSANNA MOBERLY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 KEENE CENTRE DR
NICHOLASVILLE KY
40356-1492
US

IV. Provider business mailing address

459 KEENE CENTRE DR
NICHOLASVILLE KY
40356-1492
US

V. Phone/Fax

Practice location:
  • Phone: 859-241-1136
  • Fax: 859-241-1009
Mailing address:
  • Phone: 859-241-1136
  • Fax: 859-241-1009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3009443
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3009443
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number3009443
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number3009443
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: