Healthcare Provider Details

I. General information

NPI: 1801724083
Provider Name (Legal Business Name): JUSTIN AARON UNDERWOOD
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE
ATLANTA GA
30308-2212
US

IV. Provider business mailing address

2094 SHADY LN
TUCKER GA
30084-5509
US

V. Phone/Fax

Practice location:
  • Phone: 404-686-4411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License NumberRN259763
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN259763
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: