Provider Demographics
NPI:1508530676
Name:MOODY, JULIE RAYE (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:RAYE
Last Name:MOODY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:992 SOUTH BUTTE ROAD
Mailing Address - Street 2:
Mailing Address - City:MENAN
Mailing Address - State:ID
Mailing Address - Zip Code:83434
Mailing Address - Country:US
Mailing Address - Phone:208-993-0878
Mailing Address - Fax:
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1605
Practice Address - Country:US
Practice Address - Phone:208-359-4840
Practice Address - Fax:208-359-9010
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID691402084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry