Provider Demographics
NPI:1093407330
Name:EBNER, KYLIE BROOKE (RN)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:BROOKE
Last Name:EBNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14520 MAGNOLIA BLVD APT 108
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1491
Mailing Address - Country:US
Mailing Address - Phone:805-657-2446
Mailing Address - Fax:
Practice Address - Street 1:4400 COLDWATER CANYON AVE STE 127
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-5038
Practice Address - Country:US
Practice Address - Phone:805-657-2446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95148869163WE0003X, 163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Multi-Specialty
No163WE0003XNursing Service ProvidersRegistered NurseEmergencyGroup - Multi-Specialty