Provider Demographics
NPI:1255989943
Name:KOONTZ, KELLIE PRESLAR (NP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:PRESLAR
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-713-9800
Mailing Address - Fax:336-713-9641
Practice Address - Street 1:1200 N MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3006
Practice Address - Country:US
Practice Address - Phone:336-713-9800
Practice Address - Fax:336-713-9641
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012173363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner