MEDICARE: KYLIE MOBERG

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	363LF0000X	Family Nurse Practitioner	95024464	CA

General Provider Information

NPI Number	:	1750218848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLIE MOBERG

Provider Business Mailing Address
First Line	:	22725 CANYON LAKE DR N
Second Line	:
City	:	CANYON LAKE
State	:	CA
Zip	:	92587-8014
Country	:	US
Telephone Number	:	951-723-0984
Fax Number	:

Provider Business Practice Location Address
First Line	:	22725 CANYON LAKE DR N
Second Line	:
City	:	CANYON LAKE
State	:	CA
Zip	:	92587-8014
Country	:	US
Telephone Number	:	951-723-0984
Fax Number	:

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

Provider Enumeration Date	:	05/05/2026
Last Update Date	:	05/05/2026

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