=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033088422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT MIDSOUTH INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2025
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4512 TROUT VALLEY DR
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38141-7724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-584-8165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3169 PLAYERS CLUB PKWY
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38125-8835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-584-8165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARQUITA WILLIAMS
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 901-584-8165
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------