Provider Demographics
NPI:1669475141
Name:UNDERWOOD, LILIA ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LILIA
Middle Name:ANN
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GRAND CENTRAL MALL
Mailing Address - Street 2:SUITE 4
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4100
Mailing Address - Country:US
Mailing Address - Phone:304-485-4439
Mailing Address - Fax:304-485-6489
Practice Address - Street 1:800 GRAND CENTRAL MALL
Practice Address - Street 2:SUITE 4
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-4100
Practice Address - Country:US
Practice Address - Phone:304-485-4439
Practice Address - Fax:304-485-6489
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV41261363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7105020000Medicaid
OH2198152Medicaid
WVNP02845Medicare ID - Type UnspecifiedMEDICARE # UNDERWOOD
OH2198152Medicaid