Healthcare Provider Details

I. General information

NPI: 1275442204
Provider Name (Legal Business Name): KELLYANNE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 HENRY AVE
PHILA PA
19129-1141
US

IV. Provider business mailing address

111 ELWYN RD
MEDIA PA
19063-4622
US

V. Phone/Fax

Practice location:
  • Phone: 215-254-2026
  • Fax:
Mailing address:
  • Phone: 610-891-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: