Healthcare Provider Details

I. General information

NPI: 1982248894
Provider Name (Legal Business Name): RONDA SAMI MAHMOUD ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 MAIN AVE
CLIFTON NJ
07011-2157
US

IV. Provider business mailing address

269 CHESTNUT ST APT 104
NUTLEY NJ
07110-1687
US

V. Phone/Fax

Practice location:
  • Phone: 973-253-6000
  • Fax:
Mailing address:
  • Phone: 973-765-7487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ00979300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: