Healthcare Provider Details

I. General information

NPI: 1972575512
Provider Name (Legal Business Name): BOBBY UNDERWOOD CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 HAY LONG AVE
MOUNT PLEASANT TN
38474-1434
US

IV. Provider business mailing address

409 HAY LONG AVE
MOUNT PLEASANT TN
38474-1434
US

V. Phone/Fax

Practice location:
  • Phone: 931-379-4092
  • Fax:
Mailing address:
  • Phone: 931-379-4092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN0000105025
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN0000105025
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: