Healthcare Provider Details

I. General information

NPI: 1841602471
Provider Name (Legal Business Name): DR. KRISTEN-KAYE GOULBOURNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 N 9TH AVE
PENSACOLA FL
32504-8785
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-7710
  • Fax: 850-416-6729
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME146961
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101262279
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: