Provider Demographics
NPI:1417205162
Name:PANKONIN, SANDRA SUE (SOCIAL WORKER)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:SUE
Last Name:PANKONIN
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W. WADE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:WI
Mailing Address - Zip Code:53167
Mailing Address - Country:US
Mailing Address - Phone:262-210-5004
Mailing Address - Fax:
Practice Address - Street 1:206 W. WADE STREET
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:WI
Practice Address - Zip Code:53167
Practice Address - Country:US
Practice Address - Phone:262-210-5004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8603-120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker