Provider Demographics
NPI:1154696656
Name:UNDERWOOD, PAMELA JEAN
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
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 1:300 PIONEER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4472
Mailing Address - Country:US
Mailing Address - Phone:636-327-7357
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1366
Practice Address - Country:US
Practice Address - Phone:636-625-7734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001019230133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered