Basic Information
| Provider Information | |||||||||
| NPI: | 1477980415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LICATA | ||||||||
| FirstName: | CAMILLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 RTE 46 E | ||||||||
| Address2: | STE 450 | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735593700 | ||||||||
| FaxNumber: | 9735593700 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 BLOOMFIELD AVE | ||||||||
| Address2: | STE LL-1 | ||||||||
| City: | VERONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070441366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732334493 | ||||||||
| FaxNumber: | 9732334505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2013 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 26NJ00765000 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.