Provider Demographics
NPI:1114131356
Name:KELLY, MARY B (NP)
Entity Type:Individual
Prefix:PROF
First Name:MARY
Middle Name:B
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4746
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-8746
Mailing Address - Country:US
Mailing Address - Phone:843-294-1941
Mailing Address - Fax:843-294-1945
Practice Address - Street 1:5046 HIGHWAY 17 BYP S
Practice Address - Street 2:SUITE 202 AND SUITE 203
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-4503
Practice Address - Country:US
Practice Address - Phone:843-294-1941
Practice Address - Fax:843-294-1945
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCSC APN1721363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner