Provider Demographics
NPI:1114488814
Name:RUFFIN, CHANTILAY
Entity Type:Individual
Prefix:
First Name:CHANTILAY
Middle Name:
Last Name:RUFFIN
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 1:61 BISSELL WAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-3101
Mailing Address - Country:US
Mailing Address - Phone:760-686-0141
Mailing Address - Fax:
Practice Address - Street 1:50 ACACIA AVE
Practice Address - Street 2:MEADOWLANDS 302
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2230
Practice Address - Country:US
Practice Address - Phone:415-482-3571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA57673363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant