Provider Demographics
NPI:1528659117
Name:PANKONIN, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:PANKONIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N 12TH ST APT 310
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1137
Mailing Address - Country:US
Mailing Address - Phone:402-699-0957
Mailing Address - Fax:
Practice Address - Street 1:11605 W DODGE RD STE 4
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2566
Practice Address - Country:US
Practice Address - Phone:402-256-7360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical