MEDICARE: SUSANNA MOBERLY APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	3009443	KY
2	363L00000X	Nurse Practitioner	3009443	KY
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	3009443	KY
4	207RR0500X	Rheumatology Physician	3009443	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568843316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSANNA MOBERLY APRN

Provider Business Mailing Address
First Line	:	459 KEENE CENTRE DR
Second Line	:
City	:	NICHOLASVILLE
State	:	KY
Zip	:	40356-1492
Country	:	US
Telephone Number	:	859-241-1136
Fax Number	:	859-241-1009

Provider Business Practice Location Address
First Line	:	459 KEENE CENTRE DR
Second Line	:
City	:	NICHOLASVILLE
State	:	KY
Zip	:	40356-1492
Country	:	US
Telephone Number	:	859-241-1136
Fax Number	:	859-241-1009

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2015
Last Update Date	:	12/10/2025

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Directions to “ SUSANNA MOBERLY APRN” Practice Location

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