Provider Demographics
NPI:1053669853
Name:UNDERWOOD, JOHNNA RENEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JOHNNA
Middle Name:RENEE
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4173
Mailing Address - Country:US
Mailing Address - Phone:907-457-3711
Mailing Address - Fax:
Practice Address - Street 1:459 FARMERS LOOP RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712-1406
Practice Address - Country:US
Practice Address - Phone:907-550-0587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK613225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist