Provider Demographics
NPI:1144399809
Name:SURRETT-VESTAL, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SURRETT-VESTAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 GRADE ST
Mailing Address - Street 2:
Mailing Address - City:RURAL HALL
Mailing Address - State:NC
Mailing Address - Zip Code:27045-9772
Mailing Address - Country:US
Mailing Address - Phone:704-527-9550
Mailing Address - Fax:
Practice Address - Street 1:120 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1562
Practice Address - Country:US
Practice Address - Phone:336-765-5664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3120OtherLICENSE#