Provider Demographics
NPI:1003153750
Name:KELLEY, MARK M (RNP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:M
Credentials:RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20330 JOHN RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-5509
Mailing Address - Country:US
Mailing Address - Phone:501-821-5815
Mailing Address - Fax:
Practice Address - Street 1:6514 MEADOWRIDGE RD
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6115
Practice Address - Country:US
Practice Address - Phone:855-247-8474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP000562363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner