Provider Demographics
NPI:1649718180
Name:NEWSOME, KELLIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:NEWSOME
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 S MARSHALL ST STE 204
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5865
Mailing Address - Country:US
Mailing Address - Phone:336-739-4379
Mailing Address - Fax:336-654-0797
Practice Address - Street 1:717 S MARSHALL ST STE 204
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5865
Practice Address - Country:US
Practice Address - Phone:336-739-4379
Practice Address - Fax:366-540-7973
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-04
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5012740363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health