Provider Demographics
NPI:1417518614
Name:KELLY, MARILYN LOUISE (FNP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:LOUISE
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 FORT PIERPONT DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1381
Mailing Address - Country:US
Mailing Address - Phone:304-241-7150
Mailing Address - Fax:304-599-8917
Practice Address - Street 1:1300 FORT PIERPONT DR STE 101
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1314
Practice Address - Country:US
Practice Address - Phone:304-241-7150
Practice Address - Fax:304-599-8917
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV94648163W00000X
WVAPRN103976FNP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse