=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457078842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLIE NOBOA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2022
-----------------------------------------------------
Last Update Date | 10/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 690 S LOOP 336 W STE 120
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-270-6020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2618 WINDING CREEK WAY
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77385-8005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-647-6704
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2169629
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------