Provider Demographics
NPI:1174570808
Name:SARGENT, KIMBALL JANE-MARIE (MSN, PMHCNS-BC)
Entity type:Individual
Prefix:MRS
First Name:KIMBALL
Middle Name:JANE-MARIE
Last Name:SARGENT
Suffix:
Gender:F
Credentials:MSN, PMHCNS-BC
Other - Prefix:MS
Other - First Name:JANE
Other - Middle Name:MARIE
Other - Last Name:SARGENT-TROLLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, CS
Mailing Address - Street 1:7155 SUNSET LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-8638
Mailing Address - Country:US
Mailing Address - Phone:919-838-0804
Mailing Address - Fax:919-838-1219
Practice Address - Street 1:7155 SUNSET LAKE RD
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-8638
Practice Address - Country:US
Practice Address - Phone:919-838-0804
Practice Address - Fax:919-838-1219
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC080028101YM0800X, 364SP0808X
NC0261495-01364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10079OtherBCBS PROVIDER #
NC527619OtherVALUE OPTIONS MHS #
NC6004025Medicaid
NC232289OtherCOMPSYCH CORP. PROV #
NCC 2802004OtherUNITEDAMER.INS.CO. PROV #
NC6004025Medicaid