Healthcare Provider Details

I. General information

NPI: 1235051798
Provider Name (Legal Business Name): MEGAN MCCONKEY MOELLER IBCLC, LMT, CST-T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E STATE ST STE 100
EAGLE ID
83616-6082
US

IV. Provider business mailing address

2687 N SILVER WOLF AVE
STAR ID
83669-1073
US

V. Phone/Fax

Practice location:
  • Phone: 208-912-5682
  • Fax:
Mailing address:
  • Phone: 208-440-4570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: