Healthcare Provider Details

I. General information

NPI: 1073973343
Provider Name (Legal Business Name): AMANDA SUE UNDERWOOD R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 COMMUNITY
CLINTON MO
64735-8804
US

IV. Provider business mailing address

203 N GRAHAM ST
LEETON MO
64761-9122
US

V. Phone/Fax

Practice location:
  • Phone: 660-890-8164
  • Fax: 660-885-2393
Mailing address:
  • Phone: 660-525-5972
  • Fax: 660-855-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number118540
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number118540
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: