Provider Demographics
NPI:1417626268
Name:MOODY, AMANDA LEIGH (PMHNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:MOODY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13137 BOLD RUN HILL RD
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-7800
Mailing Address - Country:US
Mailing Address - Phone:919-691-5995
Mailing Address - Fax:
Practice Address - Street 1:3000 HIGHWOODS BLVD STE 310
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1029
Practice Address - Country:US
Practice Address - Phone:919-714-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00000000363LP0808X
NC5015000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty