Healthcare Provider Details

I. General information

NPI: 1568924264
Provider Name (Legal Business Name): ERICA JANE KELLY MANTELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3773 OLENTANGY RIVER RD
COLUMBUS OH
43214-3425
US

IV. Provider business mailing address

3773 OLENTANGY RIVER RD
COLUMBUS OH
43214-3425
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-3810
  • Fax: 614-566-3895
Mailing address:
  • Phone: 614-566-3810
  • Fax: 614-566-3895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.142940
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35.142940
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: