Provider Demographics
NPI:1104613629
Name:MENDIETA, ANGELICA M (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:M
Last Name:MENDIETA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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Mailing Address - Street 1:1032 S CESAR E CHAVEZ DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2203
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:262-408-5094
Practice Address - Street 1:1032 S CESAR E CHAVEZ DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2203
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:262-408-5094
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-21
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI16506-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner