Healthcare Provider Details

I. General information

NPI: 1104272731
Provider Name (Legal Business Name): MRS. MARY ANN SIBUG HONCULADA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ANN POLICARPIO SIBUG

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#155 E.T. CALVO MEMORIAL PKWY, STE #102
TAMUNING GU
96913
US

IV. Provider business mailing address

275 FARENHOLT AVE., SUITE G PMB 90
TAMUNING GU
96913-3217
US

V. Phone/Fax

Practice location:
  • Phone: 671-477-3472
  • Fax: 671-477-3473
Mailing address:
  • Phone: 671-477-3472
  • Fax: 671-477-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT-123
License Number StateGU
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-123
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: