Provider Demographics
NPI:1730672080
Name:KELLEY, MARCUS (CRNA)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8430 VILLAGE EDGE CIR APT 4
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-2892
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8430 VILLAGE EDGE CIR APT 4
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-2892
Practice Address - Country:US
Practice Address - Phone:239-849-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9336309367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered