Provider Demographics
NPI:1326512484
Name:RICKETTS, SURONDA (RN BSN CCE)
Entity Type:Individual
Prefix:
First Name:SURONDA
Middle Name:
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:RN BSN CCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6910
Mailing Address - Country:US
Mailing Address - Phone:336-362-6064
Mailing Address - Fax:
Practice Address - Street 1:1203 MAPLE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6910
Practice Address - Country:US
Practice Address - Phone:336-362-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC138084163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty