Healthcare Provider Details

I. General information

NPI: 1376478032
Provider Name (Legal Business Name): TERESE M MOORE RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 N MAIN ST STE 2
FREMONT NE
68025-5086
US

IV. Provider business mailing address

2642 N RIDGE ROAD DR
FREMONT NE
68025-6612
US

V. Phone/Fax

Practice location:
  • Phone: 402-459-1112
  • Fax:
Mailing address:
  • Phone: 402-620-1038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number59826
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: