Healthcare Provider Details

I. General information

NPI: 1124956396
Provider Name (Legal Business Name): BENJAMIN KISER
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2026
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 AUTUMN OAK LN
FAIRBORN OH
45324-6445
US

IV. Provider business mailing address

1602 AUTUMN OAK LN
FAIRBORN OH
45324-6445
US

V. Phone/Fax

Practice location:
  • Phone: 937-545-3583
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN.510519
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: