Provider Demographics
NPI:1124772033
Name:MARMOLL, KELLY E
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:MARMOLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 REMOUNT RD APT 10423
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6498
Mailing Address - Country:US
Mailing Address - Phone:440-539-6020
Mailing Address - Fax:
Practice Address - Street 1:16455 STATESVILLE RD
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7135
Practice Address - Country:US
Practice Address - Phone:704-801-3719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic