MEDICARE: MS. CAMILLE MARIE LICATA NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	26NJ00765000	NJ
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	26NJ00765000	NJ

General Provider Information

NPI Number	:	1477980415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAMILLE MARIE LICATA NP

Provider Business Mailing Address
First Line	:	700 RTE 46 E
Second Line	:	STE 450
City	:	FAIRFIELD
State	:	NJ
Zip	:	07004
Country	:	US
Telephone Number	:	973-559-3700
Fax Number	:	973-559-3700

Provider Business Practice Location Address
First Line	:	825 BLOOMFIELD AVE
Second Line	:	STE LL-1
City	:	VERONA
State	:	NJ
Zip	:	07044-1366
Country	:	US
Telephone Number	:	973-233-4493
Fax Number	:	973-233-4505

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2013
Last Update Date	:	01/07/2026

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