Provider Demographics
NPI:1710583810
Name:STEGALL, KIMBERLY SHRON (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SHRON
Last Name:STEGALL
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 FORT KING GEORGE DR
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:GA
Mailing Address - Zip Code:31305-9021
Mailing Address - Country:US
Mailing Address - Phone:912-580-1550
Mailing Address - Fax:
Practice Address - Street 1:2900 CHAMBLEE TUCKER RD BLDG 16
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-4148
Practice Address - Country:US
Practice Address - Phone:770-939-1288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA184714363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health