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General NPI Number Information
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NPI Number | 1952264152
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Entity Type | Organization
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Legal Business Name | IMPACT RN PLLC
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Dates
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Enumeration Date | 12/04/2025
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Last Update Date | 12/04/2025
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Provider Practice Location Address
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Address Line | 167 MERRILL ST.
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City | BRENTWOOD
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State | NY
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Zip | 11717
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Country | US
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Telephone | 631-767-9090
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Fax | 270-837-7593
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Provider Business Mailing Address
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Address Line | 248 ROUTE 25A STE 3034
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City | EAST SETAUKET
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State | NY
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Zip | 11733-2954
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Country | US
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Telephone | 631-767-9090
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Fax | 270-837-7593
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Authorized Official
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Title or Position | OWNER/MANAGING MEMBER
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Name | BRENDA MICKENS
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Credential | MSN, RN
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Telephone | 631-767-9090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number |
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License Number State |
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