Healthcare Provider Details

I. General information

NPI: 1053243840
Provider Name (Legal Business Name): RACHEL ANNE PANKONIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W MAIN ST
WATERFORD WI
53185-4100
US

IV. Provider business mailing address

611 W MAIN ST
WATERFORD WI
53185-4100
US

V. Phone/Fax

Practice location:
  • Phone: 262-534-3189
  • Fax: 262-534-4971
Mailing address:
  • Phone: 262-534-3189
  • Fax: 262-534-4971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number175867-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: