Healthcare Provider Details

I. General information

NPI: 1891906772
Provider Name (Legal Business Name): NICOLE E MENEGAKIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 E SUMNER ST
HARTFORD WI
53027-2684
US

IV. Provider business mailing address

3003 W GOOD HOPE RD
MILWAUKEE WI
53209-2042
US

V. Phone/Fax

Practice location:
  • Phone: 262-670-4000
  • Fax:
Mailing address:
  • Phone: 414-352-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number59894
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberM7941
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: