Provider Demographics
NPI:1134992985
Name:KELLY, MARION RANDY JR (MSN, APRN, FNP-BC)
Entity type:Individual
Prefix:MR
First Name:MARION
Middle Name:RANDY
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12705 WITHER STEELE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-5002
Mailing Address - Country:US
Mailing Address - Phone:704-477-2565
Mailing Address - Fax:
Practice Address - Street 1:10344 PARK RD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8505
Practice Address - Country:US
Practice Address - Phone:704-981-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023064441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily