Healthcare Provider Details

I. General information

NPI: 1790640977
Provider Name (Legal Business Name): INGRID AVILES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MOUNT PROSPECT AVE
NEWARK NJ
07104-2907
US

IV. Provider business mailing address

PO BOX 830826
PHILADELPHIA PA
19182-0826
US

V. Phone/Fax

Practice location:
  • Phone: 609-890-1050
  • Fax: 609-890-0950
Mailing address:
  • Phone: 609-890-1050
  • Fax: 609-890-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ15492000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: