Provider Demographics
NPI:1295540136
Name:KELLY, MARIE GAYLE (DO)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:GAYLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8613 HERONS COVE PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2498
Mailing Address - Country:US
Mailing Address - Phone:813-924-6354
Mailing Address - Fax:
Practice Address - Street 1:306 LIBERTY VIEW LN
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2291
Practice Address - Country:US
Practice Address - Phone:434-592-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program