Provider Demographics
NPI:1982457081
Name:IMPACT PRACTITIONER SERVICES, LLC
Entity type:Organization
Organization Name:IMPACT PRACTITIONER SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPIETOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAAZ
Authorized Official - Suffix:
Authorized Official - Credentials:AAPRN
Authorized Official - Phone:772-528-5991
Mailing Address - Street 1:3307 N INDIAN RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34946-8418
Mailing Address - Country:US
Mailing Address - Phone:772-528-5991
Mailing Address - Fax:
Practice Address - Street 1:3307 N INDIAN RIVER DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34946-8418
Practice Address - Country:US
Practice Address - Phone:772-528-5991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty