Provider Demographics
NPI:1346203700
Name:SWANSON, KELLY S (RD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:SWANSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 N SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-1431
Mailing Address - Country:US
Mailing Address - Phone:405-443-8833
Mailing Address - Fax:
Practice Address - Street 1:4525 S KLEIN AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3845
Practice Address - Country:US
Practice Address - Phone:405-749-8986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1391133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK244529115Medicare ID - Type Unspecified