Provider Demographics
NPI:1043575780
Name:SIEGRIST, KIMBERLY RAE (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RAE
Last Name:SIEGRIST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 GOVERNMENT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-6299
Mailing Address - Country:US
Mailing Address - Phone:980-859-9993
Mailing Address - Fax:
Practice Address - Street 1:154 GOVERNMENT CENTER DR
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-6299
Practice Address - Country:US
Practice Address - Phone:980-859-9993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC210237363LP0200X
NC5005698363LP0200X
NC1043575780363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006194Medicaid
NCNC7384AMedicare PIN