Organization
SIVAM DIABETES, NUTRITION AND FAMILY HEALTHCARE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MAVIS CAMALITA FAULKNOR FNP, APN, RN, RD, CD (CEO/SOCIAL ENTREPRENEUR)
(201) 618-1472
Entity
Organization
Contact information
Practice address
240 N ARLINGTON AVE, EAST ORANGE, NJ 07017-3802
(201) 618-1472
Mailing address
78 KENMORE AVENUE, NEWARK, NJ 07106
(201) 618-1472
(973) 399-3393
Taxonomy
Speciality
Code
Description
License number
State
133VN1006X
Metabolic Nutrition Registered Dietitian
0071705
IL
163WD0400X
Diabetes Educator Registered Nurse
26NR11201600
NJ
363LF0000X
Family Nurse Practitioner
Primary
26NJ00421400
NJ
Other
Enumeration date
11/01/2017
Last updated
11/01/2017
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