Healthcare Provider Details

I. General information

NPI: 1184391146
Provider Name (Legal Business Name): AMANDA CAYE MOORE DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 SOUTHWAY AVE STE 2B
LEWISTON ID
83501-2703
US

IV. Provider business mailing address

415 6TH STREET ATTN: PHYSICIAN SERVICES
LEWISTON ID
83501-2424
US

V. Phone/Fax

Practice location:
  • Phone: 208-799-5370
  • Fax:
Mailing address:
  • Phone: 208-750-7462
  • Fax: 208-750-7467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61196279
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number69128
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: