Provider Demographics
NPI:1245656479
Name:SURLA, JESSIE MARIE (DNP, BC- FNP)
Entity type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:MARIE
Last Name:SURLA
Suffix:
Gender:F
Credentials:DNP, BC- FNP
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Other - First Name:
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Mailing Address - Street 1:350 W COUNTRY CLUB RD
Mailing Address - Street 2:SUITE# 105
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5205
Mailing Address - Country:US
Mailing Address - Phone:575-624-4651
Mailing Address - Fax:575-624-4875
Practice Address - Street 1:350 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE# 105
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5205
Practice Address - Country:US
Practice Address - Phone:575-624-4651
Practice Address - Fax:575-624-4875
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMCNP-02365363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07276800Medicaid
NM342994YTYCMedicare PIN