Healthcare Provider Details

I. General information

NPI: 1568329654
Provider Name (Legal Business Name): ANTWONE S MALLORY STNA-OHIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 13222
DAYTON OH
45413-0222
US

IV. Provider business mailing address

PO BOX 13222
DAYTON OH
45413-0222
US

V. Phone/Fax

Practice location:
  • Phone: 937-269-7554
  • Fax:
Mailing address:
  • Phone: 937-269-7554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number602858401024
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: