Healthcare Provider Details

I. General information

NPI: 1104264001
Provider Name (Legal Business Name): IMPACTHEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 N 51ST BLVD
MILWAUKEE WI
53216-3235
US

IV. Provider business mailing address

3219 N 51ST BLVD
MILWAUKEE WI
53216-3235
US

V. Phone/Fax

Practice location:
  • Phone: 414-771-0543
  • Fax: 262-649-4375
Mailing address:
  • Phone: 414-771-0543
  • Fax: 262-649-4375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number10158-30
License Number StateWI

VIII. Authorized Official

Name: MRS. YVETTE JOHNSON
Title or Position: PRESIDENT
Credential: APRN
Phone: 414-771-0543