Provider Demographics
NPI:1396375036
Name:MOORE, DIANNA L (LPN, IBCLC)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 NORTH HEPTNER RD
Mailing Address - Street 2:
Mailing Address - City:ROZET
Mailing Address - State:WY
Mailing Address - Zip Code:82727
Mailing Address - Country:US
Mailing Address - Phone:307-670-2110
Mailing Address - Fax:
Practice Address - Street 1:85 NORTH HEPTNER RD
Practice Address - Street 2:
Practice Address - City:ROZET
Practice Address - State:WY
Practice Address - Zip Code:82727
Practice Address - Country:US
Practice Address - Phone:307-670-2110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-97968174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN