Healthcare Provider Details

I. General information

NPI: 1104613629
Provider Name (Legal Business Name): ANGELICA M MENDIETA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 S CESAR E CHAVEZ DR
MILWAUKEE WI
53204-2203
US

IV. Provider business mailing address

1032 S CESAR E CHAVEZ DR
MILWAUKEE WI
53204-2203
US

V. Phone/Fax

Practice location:
  • Phone: 414-672-1353
  • Fax: 262-408-5094
Mailing address:
  • Phone: 414-672-1353
  • Fax: 262-408-5094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16506-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: