Basic Information
| Provider Information | |||||||||
| NPI: | 1104193945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANOCCHIO | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | LYNETTE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621305 | ||||||||
| FaxNumber: | 9375227513 | ||||||||
| Practice Location | |||||||||
| Address1: | 2115 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373846800 | ||||||||
| FaxNumber: | 9373846939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2011 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 58.004216 | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 34011470 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0112512 | 05 | OH | MEDICAID |