Provider Demographics
NPI:1295021483
Name:IMMANUEL, CAMILLE NINA (MD MHS)
Entity Type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:NINA
Last Name:IMMANUEL
Suffix:
Gender:F
Credentials:MD MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 SYCAMORE RD
Mailing Address - Street 2:APT C
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-7330
Mailing Address - Country:US
Mailing Address - Phone:276-451-4700
Mailing Address - Fax:
Practice Address - Street 1:4100 COBSCOOK DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5706
Practice Address - Country:US
Practice Address - Phone:276-451-4700
Practice Address - Fax:276-451-4700
Is Sole Proprietor?:No
Enumeration Date:2011-06-26
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ39208000000X
UT10549592-12052080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ#39OtherSTUDENT & EDUCATION