Basic Information
| Provider Information | |||||||||
| NPI: | 1073973343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UNDERWOOD | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 N GRAHAM ST | ||||||||
| Address2: | |||||||||
| City: | LEETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647619122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605255972 | ||||||||
| FaxNumber: | 6608552393 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 COMMUNITY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647358804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608908164 | ||||||||
| FaxNumber: | 6608852393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2016 | ||||||||
| LastUpdateDate: | 03/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 118540 | MO | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163W00000X | 118540 | MO | N | Nursing Service Providers | Registered Nurse |
No ID Information.