Healthcare Provider Details

I. General information

NPI: 1659724946
Provider Name (Legal Business Name): LISA MENGWASSER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 HAZEL LN
FARMINGTON MO
63640-1999
US

IV. Provider business mailing address

PO BOX 957683
SAINT LOUIS MO
63195-7683
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-6751
  • Fax:
Mailing address:
  • Phone: 573-756-6751
  • Fax: 573-760-8044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2016028753
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number105320
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: