Provider Demographics
NPI:1912676180
Name:DIMEO, KAYLEE D (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:D
Last Name:DIMEO
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 1:11 E CHASE ST APT 202
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-3662
Mailing Address - Country:US
Mailing Address - Phone:608-358-9486
Mailing Address - Fax:
Practice Address - Street 1:751 S BASCOM AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2604
Practice Address - Country:US
Practice Address - Phone:408-885-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant