Provider Demographics
NPI:1316419575
Name:KILPATRICK, KAYLON ANN
Entity type:Individual
Prefix:
First Name:KAYLON
Middle Name:ANN
Last Name:KILPATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-3690
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:421 S 28TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7208
Practice Address - Country:US
Practice Address - Phone:601-261-3690
Practice Address - Fax:601-261-3684
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02754021Medicaid