MEDICARE: STACY UNDERWOOD NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	074959	NY
2	163W00000X	Registered Nurse	5	NY
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F401243-1	NY
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP3830	AZ

General Provider Information

NPI Number	:	1043325541
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY UNDERWOOD NP

Provider Business Mailing Address
First Line	:	4747 N 7TH ST
Second Line	:	SUITE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85014-3653
Country	:	US
Telephone Number	:	602-279-7655
Fax Number	:	602-264-1806

Provider Business Practice Location Address
First Line	:	1255 W BASELINE RD
Second Line	:	SUITE B258
City	:	MESA
State	:	AZ
Zip	:	85202-5820
Country	:	US
Telephone Number	:	480-820-0825
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/09/2012

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