Provider Demographics
NPI:1518586478
Name:NEWSOME, JUSTIN (MSN, APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:NEWSOME
Suffix:
Gender:M
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 SEARCY WAY
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7168
Mailing Address - Country:US
Mailing Address - Phone:270-467-7180
Mailing Address - Fax:
Practice Address - Street 1:209 FIELD ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:KY
Practice Address - Zip Code:40823-1407
Practice Address - Country:US
Practice Address - Phone:606-909-2959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28707363LF0000X
KY3014486363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019079870OtherNATIONAL CERTIFICATION
TN28707OtherAPRN LICENSE NUMBER
KY3014486OtherLICENSE NUMBER