MEDICARE: VANDELIA TEAL-SURRATT NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	17777	SC

General Provider Information

NPI Number	:	1083980700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANDELIA TEAL-SURRATT NP

Provider Business Mailing Address
First Line	:	1469 HILLIAN EDWARDS RD
Second Line	:
City	:	CHERAW
State	:	SC
Zip	:	29520-5652
Country	:	US
Telephone Number	:	843-910-7587
Fax Number	:

Provider Business Practice Location Address
First Line	:	5665 NEW NORTHSIDE DR STE 320
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-5834
Country	:	US
Telephone Number	:	404-645-7563
Fax Number	:	770-874-6884

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2012
Last Update Date	:	05/22/2015

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