Provider Demographics
NPI:1790381077
Name:CANSIBOG, MALINA
Entity Type:Individual
Prefix:MS
First Name:MALINA
Middle Name:
Last Name:CANSIBOG
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 1:923 W UNIVERSITY AVE APT 152
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3083
Mailing Address - Country:US
Mailing Address - Phone:808-284-0418
Mailing Address - Fax:
Practice Address - Street 1:923 W UNIVERSITY AVE APT 152
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3083
Practice Address - Country:US
Practice Address - Phone:808-284-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer