Provider Demographics
NPI:1790258788
Name:PETERMAN, KYLIE
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
Middle Name:
Last Name:PETERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA STE 504
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3665
Mailing Address - Country:US
Mailing Address - Phone:949-588-5800
Mailing Address - Fax:
Practice Address - Street 1:23181 VERDUGO DR STE 103A
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1313
Practice Address - Country:US
Practice Address - Phone:949-366-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty