Basic Information
| Provider Information | |||||||||
| NPI: | 1073952016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UNDERDAHL | ||||||||
| FirstName: | HANNAH | ||||||||
| MiddleName: | ELISABETH | ||||||||
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| Credential: | RN, MSN, CNM, WHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 N RAYMOND ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837049251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142500 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 E FORT ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142525 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2013 | ||||||||
| LastUpdateDate: | 08/31/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | CNM69A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LW0102X | NP1323A | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 1073952016 | 05 | ID | MEDICAID |