=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790362911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY HORSLEY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2021
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 84 MARGINAL WAY STE 800
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-874-1489
-----------------------------------------------------
Fax | 207-523-5890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 FODEN RD
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106-2327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-774-5816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD28432
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------