Healthcare Provider Details

I. General information

NPI: 1255989943
Provider Name (Legal Business Name): KELLIE PRESLAR KOONTZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N MARTIN LUTHER KING JR DR
WINSTON SALEM NC
27101-3006
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-9800
  • Fax: 336-713-9641
Mailing address:
  • Phone: 336-713-9800
  • Fax: 336-713-9641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5012173
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: