Provider Demographics
NPI:1487047775
Name:SURVANCE, DONETTE RAE (NP)
Entity type:Individual
Prefix:MRS
First Name:DONETTE
Middle Name:RAE
Last Name:SURVANCE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BROWN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7005
Mailing Address - Country:US
Mailing Address - Phone:334-273-4159
Mailing Address - Fax:334-273-4290
Practice Address - Street 1:4749 BERRY BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3079
Practice Address - Country:US
Practice Address - Phone:334-747-8850
Practice Address - Fax:334-747-8860
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19336363LF0000X
AL1-161525363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I506794OtherMEDICARE
AL512-1203OtherBCBS
AL206270Medicaid