Provider Demographics
NPI:1669885539
Name:RODOLFF, KELLEY LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:LYNN
Last Name:RODOLFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KELLEY
Other - Middle Name:LYNN
Other - Last Name:SCHWARZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1990 N CALIFORNIA BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3742
Mailing Address - Country:US
Mailing Address - Phone:925-225-5837
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2574
Practice Address - Country:US
Practice Address - Phone:707-554-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-08
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant