Basic Information
| Provider Information | |||||||||
| NPI: | 1649718180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEWSOME | ||||||||
| FirstName: | KELLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 713 S MARSHALL ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271015808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367227266 | ||||||||
| FaxNumber: | 3362010538 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 POLO RD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271063831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367227266 | ||||||||
| FaxNumber: | 3362010538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2017 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 1967917 | NC | N | Nursing Service Providers | Registered Nurse | Community Health | 363LP0808X | 5012740 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.