MEDICARE: IMPACTHEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1500X	Community Health Registered Nurse	10158-30	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104264001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACTHEALTH, LLC

Provider Business Mailing Address
First Line	:	3219 N 51ST BLVD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-3235
Country	:	US
Telephone Number	:	414-771-0543
Fax Number	:	262-649-4375

Provider Business Practice Location Address
First Line	:	3219 N 51ST BLVD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-3235
Country	:	US
Telephone Number	:	414-771-0543
Fax Number	:	262-649-4375

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. YVETTE JOHNSON
Credential	:	APRN
Telephone Number	:	414-771-0543

Provider Enumeration Date	:	06/13/2013
Last Update Date	:	01/14/2021

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