Healthcare Provider Details

I. General information

NPI: 1316730054
Provider Name (Legal Business Name): ABIGAIL GRACE WOLTHOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2025
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 SOUTHERN BLVD
KETTERING OH
45429-1264
US

IV. Provider business mailing address

1 PRESTIGE PL STE 550
MIAMISBURG OH
45342-6115
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-4331
  • Fax: 937-395-6668
Mailing address:
  • Phone: 937-762-1306
  • Fax: 937-522-7017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.010498RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: