MEDICARE: ANTWONE S MALLORY STNA-OHIO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	602858401024	OH

General Provider Information

NPI Number	:	1568329654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTWONE S MALLORY STNA-OHIO

Provider Business Mailing Address
First Line	:	2980 STOP 8 RD APT 17
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-3139
Country	:	US
Telephone Number	:	937-269-7554
Fax Number	:

Provider Business Practice Location Address
First Line	:	2980 STOP 8 RD APT 17
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-3139
Country	:	US
Telephone Number	:	937-269-7554
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2026
Last Update Date	:	01/11/2026

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Directions to “ ANTWONE S MALLORY STNA-OHIO” Practice Location

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