Individual provider · NPI-1

Dr. Mavis Camalita Ermakov, R.D., RN., CDE., APN

Nurse Practitioner, Family · Newark, NJ

NPI number1265614911
StatusActive
Last updated in NPPESAug 17, 2021

Details

NPI
1265614911
Entity type
Individual (NPI-1)
Name
Dr. Mavis Camalita Ermakov
Credential
R.D., RN., CDE., APN
Sex
Female
Sole proprietor
No
Enumeration date
Dec 4, 2007
Certification date
Aug 17, 2021
Last updated
Aug 17, 2021

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
363LF0000X Nurse Practitioner, Family26NJ00421400NJYes
133V00000X Dietitian, Registered0071705IL
133VN1006X Dietitian, Registered, Nutrition, Metabolic717052 (ID#)IL
163WD0400X Registered Nurse, Diabetes Educator26NR112011600NJ

Practice location

741 Broadway
Newark, NJ 07104-4309

Phone 973-483-1300

Mailing address

731 Liberty Ct
Piscataway, NJ 08854-7206

Phone 732-937-5952

Other practice locations

731 Liberty Ct
Piscataway, NJ 08854-7206

Phone 732-937-5952

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