Provider Demographics
NPI:1043325541
Name:UNDERWOOD, STACY (NP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 N 7TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3653
Mailing Address - Country:US
Mailing Address - Phone:602-279-7655
Mailing Address - Fax:602-264-1806
Practice Address - Street 1:1255 W BASELINE RD
Practice Address - Street 2:SUITE B258
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5820
Practice Address - Country:US
Practice Address - Phone:480-820-0825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0749591041C0700X
NY5163W00000X
NYF401243-1363LP0808X
AZAP3830363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse