Healthcare Provider Details

I. General information

NPI: 1225994593
Provider Name (Legal Business Name): KATHLEEN CLARK SABOURAULT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATIE SABOURAULT APRN

II. Dates (important events)

Enumeration Date: 12/31/2025
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N ORANGE AVE STE 502
ORLANDO FL
32804-5503
US

IV. Provider business mailing address

2012 BAY CLOVER DR
WINTER GARDEN FL
34787-8843
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2801
  • Fax: 407-303-2805
Mailing address:
  • Phone: 863-634-3594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11040919
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number9388260
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: