Healthcare Provider Details

I. General information

NPI: 1215703483
Provider Name (Legal Business Name): HALO NIKOLAEVNA PANCAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 W DRAGOON TRL
MISHAWAKA IN
46544-4713
US

IV. Provider business mailing address

317 N ELDER ST
MISHAWAKA IN
46544-4065
US

V. Phone/Fax

Practice location:
  • Phone: 480-578-1017
  • Fax:
Mailing address:
  • Phone: 480-578-1017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-90668
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: