=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073973343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA SUE UNDERWOOD R.N.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2016
-----------------------------------------------------
Last Update Date | 03/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 COMMUNITY
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64735-8804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-890-8164
-----------------------------------------------------
Fax | 660-885-2393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 N GRAHAM ST
-----------------------------------------------------
City | LEETON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64761-9122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-525-5972
-----------------------------------------------------
Fax | 660-855-2393
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
-----------------------------------------------------
License Number | 118540
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 118540
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------