Healthcare Provider Details

I. General information

NPI: 1487965497
Provider Name (Legal Business Name): KIMBERLY BOGARD HORNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WINDERLEY PL STE 115
MAITLAND FL
32751-7406
US

IV. Provider business mailing address

1567 TEA OLIVE WAY
OVIEDO FL
32765-2012
US

V. Phone/Fax

Practice location:
  • Phone: 407-875-0555
  • Fax:
Mailing address:
  • Phone: 724-787-1969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT 197513
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: