Provider Demographics
NPI:1265320857
Name:NORTHAM, KAYLEE RENE (RBT)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:RENE
Last Name:NORTHAM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 RAPTOR TER NE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-6402
Mailing Address - Country:US
Mailing Address - Phone:910-757-6386
Mailing Address - Fax:
Practice Address - Street 1:1240 MAGNOLIA VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-9464
Practice Address - Country:US
Practice Address - Phone:910-599-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBACB1219452374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician