Provider Demographics
NPI:1457587602
Name:SWADE, KELLY MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE
Last Name:SWADE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:6633 TELEPHONE RD STE 212
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5569
Practice Address - Country:US
Practice Address - Phone:310-301-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015041241207Q00000X
KS05-37491207Q00000X
CA20A20448207QA0505X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine