Healthcare Provider Details

I. General information

NPI: 1306114483
Provider Name (Legal Business Name): VICKIE LYNN SORRELL FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 01/21/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 S RIDGEWOOD AVE
PORT ORANGE FL
32127-4544
US

IV. Provider business mailing address

1 WARRIOR WAY
BELLE WV
25015-1356
US

V. Phone/Fax

Practice location:
  • Phone: 386-761-0050
  • Fax:
Mailing address:
  • Phone: 304-949-3591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number58087
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9420904
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2011007183
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9420904
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: