Healthcare Provider Details

I. General information

NPI: 1366062572
Provider Name (Legal Business Name): TANYA UNDERWOOD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 S MADISON ST
TUPELO MS
38801-6309
US

IV. Provider business mailing address

1109 WALNUT ST
AMORY MS
38821-3715
US

V. Phone/Fax

Practice location:
  • Phone: 662-844-8754
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number905071
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number865557
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: