Provider Demographics
NPI:1679368492
Name:BOUGH, SERENA (IBCLC)
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:BOUGH
Suffix:
Gender:
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 OCEAN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89441-5542
Mailing Address - Country:US
Mailing Address - Phone:406-839-8186
Mailing Address - Fax:
Practice Address - Street 1:499 W PLUMB LN STE 101
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3778
Practice Address - Country:US
Practice Address - Phone:775-453-4628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVL-142511174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN