Basic Information
| Provider Information | |||||||||
| NPI: | 1679551402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORNE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, MSN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9782 HWY 903 | ||||||||
| Address2: | |||||||||
| City: | BRACEY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239191991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346366903 | ||||||||
| FaxNumber: | 4346363826 | ||||||||
| Practice Location | |||||||||
| Address1: | 9782 HWY 903 | ||||||||
| Address2: | |||||||||
| City: | BRACEY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239191991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346366903 | ||||||||
| FaxNumber: | 4346363826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200823 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080106064 | 01 | NC | RAILROAD MEDICARE # | OTHER | 5131201 | 01 | NC | CCN/FIRST HEALTH # | OTHER | 84854 | 01 | NC | MEDCOST LLC PROVIDER # | OTHER | P01159044 | 01 | VA | RAILROAD MEDICARE | OTHER | MH0229953 | 01 | NC | DEA CERTIFICATE # | OTHER | 0024169059 | 01 | VA | VA LICENSE # | OTHER | 200823 | 01 | NC | NC MEDICAL LICENSE # | OTHER |