Provider Demographics
NPI:1154406411
Name:SURRATT, VICKY GAYE (MA FNP-BC)
Entity type:Individual
Prefix:MS
First Name:VICKY
Middle Name:GAYE
Last Name:SURRATT
Suffix:
Gender:F
Credentials:MA FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 ASHLEYBROOK SQUARE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-765-6577
Mailing Address - Fax:
Practice Address - Street 1:125 ASHLEYBROOK SQUARE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-765-6577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1272103T00000X
NC22112363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005004Medicaid
NC6005004Medicaid
2599517BMedicare ID - Type Unspecified