Healthcare Provider Details

I. General information

NPI: 1114110665
Provider Name (Legal Business Name): MICHELLE B SURRETT FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2007
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3799 12TH STREET EXT STE 110
CAYCE SC
29033-3750
US

IV. Provider business mailing address

PO BOX 6069
WEST COLUMBIA SC
29171-6069
US

V. Phone/Fax

Practice location:
  • Phone: 803-755-3337
  • Fax: 803-955-2225
Mailing address:
  • Phone: 803-935-8292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number1009
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: