Healthcare Provider Details

I. General information

NPI: 1659410405
Provider Name (Legal Business Name): DIANE L UNDERWOOD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PARK BLVD
ROGERSVILLE TN
37857-2919
US

IV. Provider business mailing address

706 OUTER DR
ROGERSVILLE TN
37857-3406
US

V. Phone/Fax

Practice location:
  • Phone: 423-272-7641
  • Fax: 423-921-8073
Mailing address:
  • Phone: 423-272-8464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN0000059100
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: