Provider Demographics
NPI:1932248515
Name:SUMMERALL, VIRGINIA W (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:W
Last Name:SUMMERALL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:VIRGINIA
Other - Middle Name:W
Other - Last Name:WHITEHEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:338 E COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:BATESBURG LEESVILLE
Practice Address - State:SC
Practice Address - Zip Code:29070-9285
Practice Address - Country:US
Practice Address - Phone:803-604-0066
Practice Address - Fax:803-604-9924
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC123363LF0000X
SCAPRN 123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPO444Medicaid
SCP16529Medicare UPIN