Healthcare Provider Details

I. General information

NPI: 1942085410
Provider Name (Legal Business Name): OPTIMOM LACTATION SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7620 SW 5TH PL
GAINESVILLE FL
32607-1572
US

IV. Provider business mailing address

7620 SW 5TH PL
GAINESVILLE FL
32607-1572
US

V. Phone/Fax

Practice location:
  • Phone: 808-468-6455
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MOORE
Title or Position: AUTHORIZED MEMBER
Credential: RN, IBCLC
Phone: 352-514-0281