Provider Demographics
NPI:1740628791
Name:UNDERHILL, HEATHER NICOLE (DO)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:NICOLE
Last Name:UNDERHILL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-2502
Mailing Address - Country:US
Mailing Address - Phone:607-734-7982
Mailing Address - Fax:
Practice Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3230
Practice Address - Country:US
Practice Address - Phone:607-271-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284889207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program