Provider Demographics
NPI:1124036728
Name:DEMONBREUN, KAHLIL AHMADI (DNP, WHNP-BC, ANP-BC)
Entity Type:Individual
Prefix:DR
First Name:KAHLIL
Middle Name:AHMADI
Last Name:DEMONBREUN
Suffix:
Gender:M
Credentials:DNP, WHNP-BC, ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6439 GARNERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1638
Mailing Address - Country:US
Mailing Address - Phone:803-776-4000
Mailing Address - Fax:
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPRN 2202363LA2200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPO649Medicaid
SCAA03717006Medicare PIN
SCAA03717499Medicare PIN
SCAA03718798Medicare PIN
SCAA03715281Medicare PIN
SCAA03715277Medicare PIN
SCQ13385Medicare UPIN
SCAA03717126Medicare PIN
SCAA03717522Medicare PIN
SCAA03717819Medicare PIN
SCAA03716868Medicare PIN
SCAA03715282Medicare PIN
SCAA03716834Medicare PIN
SCAA03717498Medicare PIN
SCAA03716882Medicare PIN
SCAA03717555Medicare PIN
SCAA03711352Medicare PIN