MEDICARE: KATELYN PANKONIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1528659117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN PANKONIN

Provider Business Mailing Address
First Line	:	225 N 12TH ST APT 310
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68102-1137
Country	:	US
Telephone Number	:	402-699-0957
Fax Number	:

Provider Business Practice Location Address
First Line	:	11605 W DODGE RD STE 4
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68154-2566
Country	:	US
Telephone Number	:	402-256-7360
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2021
Last Update Date	:	01/27/2021

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Directions to “ KATELYN PANKONIN ” Practice Location

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