Provider Demographics
NPI:1073952016
Name:UNDERDAHL, HANNAH ELISABETH (RN, MSN, CNM, WHNP)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:ELISABETH
Last Name:UNDERDAHL
Suffix:
Gender:F
Credentials:RN, MSN, CNM, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:6565 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8737
Practice Address - Country:US
Practice Address - Phone:208-514-2510
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNM69A367A00000X
IDNP1323A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1073952016Medicaid
ID20009272Medicare PIN
ID20009271Medicare PIN
ID1073952016Medicaid
ID20009269Medicare PIN