Provider Demographics
NPI:1336417476
Name:IMPACT MEDICAL LLC
Entity Type:Organization
Organization Name:IMPACT MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APN-C/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IHUOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTIH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:267-474-1355
Mailing Address - Street 1:244 AMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEMENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:244 AMAN AVE
Practice Address - Street 2:
Practice Address - City:CLEMENTON
Practice Address - State:NJ
Practice Address - Zip Code:08021-2502
Practice Address - Country:US
Practice Address - Phone:267-474-1355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-04
Last Update Date:2011-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00349900363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty