Provider Demographics
NPI:1386375244
Name:WILKES, KELLYN ELISE (DO)
Entity type:Individual
Prefix:
First Name:KELLYN
Middle Name:ELISE
Last Name:WILKES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 N BROAD ST
Mailing Address - Street 2:BOYER - SUITE 226
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4105
Mailing Address - Country:US
Mailing Address - Phone:610-331-1214
Mailing Address - Fax:
Practice Address - Street 1:3501 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4147
Practice Address - Country:US
Practice Address - Phone:215-707-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOT023106207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program