Provider Demographics
NPI:1104380898
Name:PANGANI, JOLENE FLORENCE (ATC)
Entity type:Individual
Prefix:MS
First Name:JOLENE
Middle Name:FLORENCE
Last Name:PANGANI
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 DUBOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-3826
Mailing Address - Country:US
Mailing Address - Phone:574-344-6742
Mailing Address - Fax:
Practice Address - Street 1:19600 DUBOIS AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-3826
Practice Address - Country:US
Practice Address - Phone:574-344-6742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X, 390200000X
IN36003479A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program