Healthcare Provider Details

I. General information

NPI: 1518214634
Provider Name (Legal Business Name): UNDREA NASH OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GRAND AVE
YAZOO CITY MS
39194-2319
US

IV. Provider business mailing address

700 MEADOW VIEW CV
BYRAM MS
39272-5604
US

V. Phone/Fax

Practice location:
  • Phone: 662-746-4621
  • Fax:
Mailing address:
  • Phone: 601-371-0033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License NumberOT1332
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: