Provider Demographics
NPI:1841770609
Name:RALPH, KELLIE (PA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:RALPH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:831-649-0770
Mailing Address - Fax:
Practice Address - Street 1:26 RANCHO DEL MAR
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3973
Practice Address - Country:US
Practice Address - Phone:831-649-0770
Practice Address - Fax:831-649-0142
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55807363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical