Healthcare Provider Details

I. General information

NPI: 1477964971
Provider Name (Legal Business Name): ELIZA MAE TANGONAN APN-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WALNUT AVE STE 210
CLARK NJ
07066-1269
US

IV. Provider business mailing address

100 WALNUT AVE STE 210
CLARK NJ
07066-1269
US

V. Phone/Fax

Practice location:
  • Phone: 973-620-2774
  • Fax:
Mailing address:
  • Phone: 973-620-2774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00498900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: