Provider Demographics
NPI:1447544630
Name:PRATT, GLENNISE DANEEN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:GLENNISE
Middle Name:DANEEN
Last Name:PRATT
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:36320 INLAND VALLEY DR
Mailing Address - Street 2:307
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7512
Mailing Address - Country:US
Mailing Address - Phone:951-600-0110
Mailing Address - Fax:951-600-1489
Practice Address - Street 1:36320 INLAND VALLEY DRIVE
Practice Address - Street 2:307
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9083
Practice Address - Country:US
Practice Address - Phone:951-600-0110
Practice Address - Fax:951-600-1489
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-05
Last Update Date:2016-02-11
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Provider Licenses
StateLicense IDTaxonomies
CAPA21581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant