=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225828544
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOW LACTATION PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2025
-----------------------------------------------------
Last Update Date | 05/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7225 N ORIOLE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60631-4253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-242-8447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7225 N ORIOLE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60631-4253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-242-8447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARGARET C JOHNSON
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 309-242-8447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------