Healthcare Provider Details

I. General information

NPI: 1134992985
Provider Name (Legal Business Name): MARION RANDY KELLY JR. MSN, APRN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10344 PARK RD STE 300
CHARLOTTE NC
28210-8505
US

IV. Provider business mailing address

10344 PARK RD STE 300
CHARLOTTE NC
28210-8505
US

V. Phone/Fax

Practice location:
  • Phone: 704-228-6994
  • Fax:
Mailing address:
  • Phone: 704-477-2565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2023064441
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: