Healthcare Provider Details

I. General information

NPI: 1447791363
Provider Name (Legal Business Name): DESIREE A MENGO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 MCHENRY ST
BURLINGTON WI
53105
US

IV. Provider business mailing address

248 MCHENRY ST
BURLINGTON WI
53105-1828
US

V. Phone/Fax

Practice location:
  • Phone: 262-767-8000
  • Fax: 262-767-8190
Mailing address:
  • Phone: 262-767-8000
  • Fax: 262-767-8190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7584-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7584-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: