Provider Demographics
NPI:1043859879
Name:PANKIN, NICOLE LESLIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LESLIE
Last Name:PANKIN
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 1:650 W 171ST ST APT 3C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3130
Mailing Address - Country:US
Mailing Address - Phone:646-599-2452
Mailing Address - Fax:
Practice Address - Street 1:6143 186TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2710
Practice Address - Country:US
Practice Address - Phone:929-200-7105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist