Basic Information
| Provider Information | |||||||||
| NPI: | 1548890916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGANTO | ||||||||
| FirstName: | DIVINE | ||||||||
| MiddleName: | MANSIBA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 COWL ST, #21 | ||||||||
| Address2: | |||||||||
| City: | MILTON FREEWATER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97862 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 NE 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | MILTON FREEWATER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419385693 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2020 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376K00000X | Y | Nursing Service Related Providers | Nurse's Aide |
No ID Information.