Provider Demographics
NPI:1144697301
Name:UNDERWOOD, CAROL G
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:G
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1484 W 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-3339
Mailing Address - Country:US
Mailing Address - Phone:870-887-0155
Mailing Address - Fax:
Practice Address - Street 1:1484 W 1ST ST N
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857-3339
Practice Address - Country:US
Practice Address - Phone:870-887-0155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01154363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology