Provider Demographics
NPI:1639364409
Name:NEWSOME, KELLY L (PNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:NEWSOME
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:NEWCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1367
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75483-1367
Mailing Address - Country:US
Mailing Address - Phone:903-438-3336
Mailing Address - Fax:903-438-3385
Practice Address - Street 1:105 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2136
Practice Address - Country:US
Practice Address - Phone:903-885-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX688654363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206333102Medicaid
TX350528YLZNMedicare PIN
TXTXB118197Medicare Oscar/Certification
TX8Y2772OtherBCBS OF TEXAS
TN206333101Medicaid