Provider Demographics
NPI:1194266023
Name:REYNOLDS, AMANDA DEWITT (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:DEWITT
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 N HOWE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-3038
Mailing Address - Country:US
Mailing Address - Phone:910-457-3808
Mailing Address - Fax:910-457-3842
Practice Address - Street 1:924 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3038
Practice Address - Country:US
Practice Address - Phone:910-457-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1158155363LP0808X
NC5009418363LP0808X, 363LF0000X
COC-APRN.0102208-C-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health