Healthcare Provider Details

I. General information

NPI: 1285204982
Provider Name (Legal Business Name): ALLISON NICOLE MANCZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 SOUTHERN BLVD STE 101
KETTERING OH
45429-1265
US

IV. Provider business mailing address

271 GLENBURN DR
CENTERVILLE OH
45459-2116
US

V. Phone/Fax

Practice location:
  • Phone: 937-281-3810
  • Fax: 937-281-3812
Mailing address:
  • Phone: 937-694-7393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0029115
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberAPRN.CNP.0029115
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: