Provider Demographics
NPI:1447791363
Name:MENGO, DESIREE A (NP)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:A
Last Name:MENGO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 MCHENRY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1828
Mailing Address - Country:US
Mailing Address - Phone:262-767-8000
Mailing Address - Fax:262-767-8190
Practice Address - Street 1:248 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105
Practice Address - Country:US
Practice Address - Phone:262-767-8000
Practice Address - Fax:262-767-8190
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7584-33363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10006568Medicaid