Basic Information
| Provider Information | |||||||||
| NPI: | 1447544630 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRATT | ||||||||
| FirstName: | GLENNISE | ||||||||
| MiddleName: | DANEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36320 INLAND VALLEY DR | ||||||||
| Address2: | 307 | ||||||||
| City: | WILDOMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925957512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516000110 | ||||||||
| FaxNumber: | 9516001489 | ||||||||
| Practice Location | |||||||||
| Address1: | 36320 INLAND VALLEY DRIVE | ||||||||
| Address2: | 307 | ||||||||
| City: | WILDOMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925959083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516000110 | ||||||||
| FaxNumber: | 9516001489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2011 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA21581 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.