Provider Demographics
NPI:1548830086
Name:SURBER, MARY LOU (FNP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:SURBER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:648 ALLEN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WAVERLY HALL
Mailing Address - State:GA
Mailing Address - Zip Code:31831-2944
Mailing Address - Country:US
Mailing Address - Phone:703-431-3743
Mailing Address - Fax:
Practice Address - Street 1:6509 GATEWAY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-5681
Practice Address - Country:US
Practice Address - Phone:706-243-0174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN190884363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily