Healthcare Provider Details

I. General information

NPI: 1790362911
Provider Name (Legal Business Name): KELLY HORSLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 MARGINAL WAY STE 800
PORTLAND ME
04101-2475
US

IV. Provider business mailing address

100 FODEN RD
SOUTH PORTLAND ME
04106-2327
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-1489
  • Fax: 207-523-5890
Mailing address:
  • Phone: 207-774-5816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD28432
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: