Provider Demographics
NPI:1790392959
Name:MADOUN, THERESA HOPE (RN, BSN, IBCLC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:HOPE
Last Name:MADOUN
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3362 PARKLAND DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3362 PARKLAND DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-1828
Practice Address - Country:US
Practice Address - Phone:248-425-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704321895163WN0002X
MIL-157742163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care