Provider Demographics
NPI:1689255564
Name:UNDERWOOD, AUTUMN
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
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 1:165 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-4305
Mailing Address - Country:US
Mailing Address - Phone:917-415-0157
Mailing Address - Fax:
Practice Address - Street 1:165 PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-4305
Practice Address - Country:US
Practice Address - Phone:917-415-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY544384163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse