Provider Demographics
NPI:1588045553
Name:UNDERWOOD, VANDY
Entity Type:Individual
Prefix:
First Name:VANDY
Middle Name:
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 1:630 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3726
Mailing Address - Country:US
Mailing Address - Phone:616-834-6580
Mailing Address - Fax:
Practice Address - Street 1:630 E 11TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3726
Practice Address - Country:US
Practice Address - Phone:616-834-6580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110986164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse