Healthcare Provider Details

I. General information

NPI: 1003780297
Provider Name (Legal Business Name): ANTHONY JACOB CISNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 BROCONE DR
VANDALIA OH
45377-1901
US

IV. Provider business mailing address

321 BROCONE DR
VANDALIA OH
45377-1901
US

V. Phone/Fax

Practice location:
  • Phone: 937-630-1901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: