Individual
KELLY RYAN WACKERLE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
2801 RANDOLPH RD STE 100, CHARLOTTE, NC 28211-1051
(704) 367-4800
(704) 316-3025
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
Taxonomy
Speciality
Code
Description
License number
State
207T00000X
Neurological Surgery Physician
Primary
2024-02000
NC
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/03/2017
Last updated
10/16/2025
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