Healthcare Provider Details

I. General information

NPI: 1265614911
Provider Name (Legal Business Name): MAVIS CAMALITA ERMAKOV R.D., RN., CDE., APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 BROADWAY
NEWARK NJ
07104-4309
US

IV. Provider business mailing address

731 LIBERTY CT
PISCATAWAY NJ
08854-7206
US

V. Phone/Fax

Practice location:
  • Phone: 973-483-1300
  • Fax:
Mailing address:
  • Phone: 732-937-5952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00421400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0071705
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number717052 (ID#)
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number26NR112011600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: