Provider Demographics
NPI:1073687760
Name:GUIMARY, IMELDA DE VERA (NP)
Entity Type:Individual
Prefix:MRS
First Name:IMELDA
Middle Name:DE VERA
Last Name:GUIMARY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1600
Mailing Address - Country:US
Mailing Address - Phone:862-596-4300
Mailing Address - Fax:
Practice Address - Street 1:268 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2011
Practice Address - Country:US
Practice Address - Phone:201-512-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ000899163W00000X
NJ26NJ0008990363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ221775306Medicaid
NJ6301703Medicaid