Provider Demographics
NPI:1386683589
Name:KIMBALL, JANICE LOUISE (NP)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:LOUISE
Last Name:KIMBALL
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 1:4420 LAKE BOONE TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7505
Mailing Address - Country:US
Mailing Address - Phone:919-784-3298
Mailing Address - Fax:919-784-6176
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:PALLIATIVE CARE OFFICE
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:919-784-3298
Practice Address - Fax:919-784-6176
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF440034-1363LA2200X
NC900075363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS21798Medicare UPIN