Basic Information
| Provider Information | |||||||||
| NPI: | 1447791363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENGO | ||||||||
| FirstName: | DESIREE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 248 MCHENRY ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531051828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627678000 | ||||||||
| FaxNumber: | 2627678190 | ||||||||
| Practice Location | |||||||||
| Address1: | 248 MCHENRY ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627678000 | ||||||||
| FaxNumber: | 2627678190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2017 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 7584-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 7584-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 10006568 | 05 | WI | MEDICAID |