Healthcare Provider Details

I. General information

NPI: 1215211529
Provider Name (Legal Business Name): STACEY MARIE DIANTONIO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4124 MUNSON ST NW
CANTON OH
44718-2979
US

IV. Provider business mailing address

29111 CEDAR RD
MAYFIELD HEIGHTS OH
44124-4005
US

V. Phone/Fax

Practice location:
  • Phone: 234-410-7546
  • Fax:
Mailing address:
  • Phone: 440-646-1600
  • Fax: 440-646-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003342
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: