Provider Demographics
NPI:1407512403
Name:BAGBY, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BAGBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 LLOYD ST STE 260
Mailing Address - Street 2:
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-1856
Mailing Address - Country:US
Mailing Address - Phone:919-240-4561
Mailing Address - Fax:
Practice Address - Street 1:209 LLOYD ST STE 260
Practice Address - Street 2:
Practice Address - City:CARRBORO
Practice Address - State:NC
Practice Address - Zip Code:27510-1856
Practice Address - Country:US
Practice Address - Phone:919-240-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-14
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC274815163W00000X
NC5015639363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse