Provider Demographics
NPI:1881152510
Name:EDZIAH, MERCY K (MS, RD, CDCES)
Entity type:Individual
Prefix:
First Name:MERCY
Middle Name:K
Last Name:EDZIAH
Suffix:
Gender:F
Credentials:MS, RD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 MOUNT PROSPECT AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-3110
Mailing Address - Country:US
Mailing Address - Phone:201-207-2158
Mailing Address - Fax:201-604-4639
Practice Address - Street 1:654 MOUNT PROSPECT AVE STE 302
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3110
Practice Address - Country:US
Practice Address - Phone:201-207-2158
Practice Address - Fax:201-604-4639
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL86020214133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1194284844OtherORGANIZATION NPI