Provider Demographics
NPI:1649707027
Name:DEPANICIS, KAYLA N (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:N
Last Name:DEPANICIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 W SAINT ISABEL ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6318
Mailing Address - Country:US
Mailing Address - Phone:813-874-5707
Mailing Address - Fax:
Practice Address - Street 1:6901 SIMMONS LOOP
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-9498
Practice Address - Country:US
Practice Address - Phone:813-874-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA08425363AM0700X
FLPA9112165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical