Provider Demographics
NPI:1114599214
Name:GOOLSBY, NAKEYTA (PMHNP)
Entity Type:Individual
Prefix:
First Name:NAKEYTA
Middle Name:
Last Name:GOOLSBY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 PEE DEE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-4945
Mailing Address - Country:US
Mailing Address - Phone:866-272-7826
Mailing Address - Fax:
Practice Address - Street 1:4140 CHERRY ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-2536
Practice Address - Country:US
Practice Address - Phone:866-272-7826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021028920363LP0808X
NCGOOL-FO8WC363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health