Provider Demographics
NPI:1841602471
Name:GOULBOURNE, KRISTEN-KAYE
Entity Type:Individual
Prefix:DR
First Name:KRISTEN-KAYE
Middle Name:
Last Name:GOULBOURNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:5153 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8785
Practice Address - Country:US
Practice Address - Phone:850-416-7710
Practice Address - Fax:850-416-6729
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME146961208000000X
VA01012622792080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101262279OtherCOMMONWEALTH OF VIRGINIA