Provider Demographics
NPI:1679041446
Name:UNDERWOOD, ETHEL LEE (STNA)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:LEE
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3995 VALLEY RD APT 2
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-3040
Mailing Address - Country:US
Mailing Address - Phone:216-778-0959
Mailing Address - Fax:
Practice Address - Street 1:3995 VALLEY RD APT 2
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-3040
Practice Address - Country:US
Practice Address - Phone:216-778-0959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400782390708376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide