Basic Information
| Provider Information | |||||||||
| NPI: | 1124036728 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMONBREUN | ||||||||
| FirstName: | KAHLIL | ||||||||
| MiddleName: | AHMADI | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP, WHNP-BC, ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6439 GARNERS FERRY RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292091638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037764000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6439 GARNERS FERRY RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292091638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037764000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | APRN 2202 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LW0102X | APRN 2202 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | NPO649 | 05 | SC | MEDICAID |