Healthcare Provider Details

I. General information

NPI: 1386292928
Provider Name (Legal Business Name): KALLIE RAYE UNDERWOOD CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9475 BRIAR VILLAGE PT STE 100
COLORADO SPRINGS CO
80920-7902
US

IV. Provider business mailing address

2090 WOODPARK DR
COLORADO SPRINGS CO
80951-4729
US

V. Phone/Fax

Practice location:
  • Phone: 719-367-9405
  • Fax:
Mailing address:
  • Phone: 316-633-1276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAPN.0994323-CNM
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: