Healthcare Provider Details

I. General information

NPI: 1760379101
Provider Name (Legal Business Name): KOURTNEY JO SURBER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 PIRATES WAY
CEDARVILLE AR
72932-9506
US

IV. Provider business mailing address

9755 W STATE HIGHWAY 22
RATCLIFF AR
72951-9000
US

V. Phone/Fax

Practice location:
  • Phone: 479-270-5242
  • Fax: 479-279-7685
Mailing address:
  • Phone: 479-431-2050
  • Fax: 479-431-2051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number233547
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: