Basic Information
| Provider Information | |||||||||
| NPI: | 1841602471 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOULBOURNE | ||||||||
| FirstName: | KRISTEN-KAYE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506063 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 5153 N 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504167710 | ||||||||
| FaxNumber: | 8504166729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2014 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME146961 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 0101262279 | VA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0101262279 | 01 | VA | COMMONWEALTH OF VIRGINIA | OTHER |