Basic Information
| Provider Information | |||||||||
| NPI: | 1003153750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20330 JOHN RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722105509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018215815 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6514 MEADOWRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ELKRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210756115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552478474 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2013 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | P000562 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.