Basic Information
| Provider Information | |||||||||
| NPI: | 1114599214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOOLSBY | ||||||||
| FirstName: | NAKEYTA | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 PEE DEE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280014945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662727826 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4140 CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271052536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662727826 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2021 | ||||||||
| LastUpdateDate: | 07/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 2021028920 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | GOOL-FO8WC | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.