Provider Demographics
NPI:1265614911
Name:ERMAKOV, MAVIS CAMALITA (RD, RN, CDE, APN)
Entity type:Individual
Prefix:DR
First Name:MAVIS
Middle Name:CAMALITA
Last Name:ERMAKOV
Suffix:
Gender:F
Credentials:RD, RN, CDE, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 LIBERTY CT
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-7206
Mailing Address - Country:US
Mailing Address - Phone:732-937-5952
Mailing Address - Fax:
Practice Address - Street 1:741 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-4309
Practice Address - Country:US
Practice Address - Phone:973-483-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0071705133V00000X
IL717052 (ID#)133VN1006X
NJ26NR112011600163WD0400X
NJ26NJ00421400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0143533620Medicaid