Provider Demographics
NPI:1164749180
Name:TEIBLOOM-MISHKIN, JUDITH (RN, IBCLC)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:
Last Name:TEIBLOOM-MISHKIN
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 1:9222 RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60203-1511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9222 RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60203-1511
Practice Address - Country:US
Practice Address - Phone:847-679-2246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.250064163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse