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General NPI Number Information
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NPI Number | 1447544630
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Entity Type | Individual
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Provider Name | GLENNISE DANEEN PRATT PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/05/2011
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Last Update Date | 02/11/2016
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Provider Practice Location Address
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Address Line | 36320 INLAND VALLEY DRIVE 307
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City | WILDOMAR
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State | CA
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Zip | 92595-9083
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Country | US
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Telephone | 951-600-0110
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Fax | 951-600-1489
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Provider Business Mailing Address
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Address Line | 36320 INLAND VALLEY DR 307
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City | WILDOMAR
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State | CA
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Zip | 92595-7512
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Country | US
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Telephone | 951-600-0110
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Fax | 951-600-1489
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA21581
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License Number State | CA
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