Healthcare Provider Details

I. General information

NPI: 1992968499
Provider Name (Legal Business Name): DR. KELLY SWEERUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MINOR AVE
SEATTLE WA
98104-2120
US

IV. Provider business mailing address

515 MINOR AVE
SEATTLE WA
98104-2120
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-9500
  • Fax: 206-576-3802
Mailing address:
  • Phone: 206-386-9500
  • Fax: 206-576-3802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA115721
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301092101
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD60431899
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: