Provider Demographics
NPI:1003428111
Name:WILMOT, KAYLA MARIE DEMUS (PA)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE DEMUS
Last Name:WILMOT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:MARIE
Other - Last Name:DEMUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6520 FORT CAROLINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2044
Mailing Address - Country:US
Mailing Address - Phone:904-745-3618
Mailing Address - Fax:904-722-4271
Practice Address - Street 1:1215 DUNN AVE STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4897
Practice Address - Country:US
Practice Address - Phone:904-745-3618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9113901363A00000X
FLPA9113901363LF0000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily