Healthcare Provider Details

I. General information

NPI: 1891159216
Provider Name (Legal Business Name): AMANDA KIMBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 ERWIN RD STE 300
DURHAM NC
27705-4597
US

IV. Provider business mailing address

2608 ERWIN RD STE 300
DURHAM NC
27705-4597
US

V. Phone/Fax

Practice location:
  • Phone: 919-681-1600
  • Fax:
Mailing address:
  • Phone: 919-385-3232
  • Fax: 919-681-1600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2021-01337
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021-01337
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: