Provider Demographics
NPI:1548890916
Name:MAGANTO, DIVINE MANSIBA
Entity type:Individual
Prefix:MS
First Name:DIVINE
Middle Name:MANSIBA
Last Name:MAGANTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 COWL ST, #21
Mailing Address - Street 2:
Mailing Address - City:MILTON FREEWATER
Mailing Address - State:OR
Mailing Address - Zip Code:97862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 NE 3RD AVE
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862
Practice Address - Country:US
Practice Address - Phone:541-938-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide