Provider Demographics
NPI:1508663576
Name:BIRCHMOON-GORDON, MAIA (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:MAIA
Middle Name:
Last Name:BIRCHMOON-GORDON
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7848 E PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-3672
Mailing Address - Country:US
Mailing Address - Phone:773-710-6242
Mailing Address - Fax:
Practice Address - Street 1:OUTPATIENT BREASTFEEDING CLINIC
Practice Address - Street 2:5140 N CALIFORNIA AVE SUITE 420
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-300200163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant