Provider Demographics
NPI:1932825791
Name:SKVARNA, KELLY MARIE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:SKVARNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 AGATE ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3325
Mailing Address - Country:US
Mailing Address - Phone:949-910-0759
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA62383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant