Basic Information
| Provider Information | |||||||||
| NPI: | 1891797304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UNDERWOOD | ||||||||
| FirstName: | MARNI | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KECK | ||||||||
| OtherFirstName: | MARNI | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 32 WICKS LN | ||||||||
| Address2: | SVP - HEIGHTS FAMILY PRACTICE | ||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591053810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062378300 | ||||||||
| FaxNumber: | 4062378333 | ||||||||
| Practice Location | |||||||||
| Address1: | 6342 PHELAN BLVD | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777066150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817838162 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 101469 | MT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | AP134988 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.