Provider Demographics
NPI:1619622693
Name:PRATT, MAKAILA AMEENA
Entity Type:Individual
Prefix:
First Name:MAKAILA
Middle Name:AMEENA
Last Name:PRATT
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 1:9430 W ROCHELLE AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-4644
Mailing Address - Country:US
Mailing Address - Phone:414-914-3216
Mailing Address - Fax:
Practice Address - Street 1:9430 W ROCHELLE AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-4644
Practice Address - Country:US
Practice Address - Phone:414-914-3216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100193229Medicaid
WI87-4499743Medicaid