Provider Demographics
NPI:1619200128
Name:PRATT, STACEY (MPA)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:PRATT
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:SHAYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2241 WANKEL WAY STE C
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-0191
Mailing Address - Country:US
Mailing Address - Phone:805-983-0922
Mailing Address - Fax:805-351-8217
Practice Address - Street 1:818 W 7TH ST STE 930
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3476
Practice Address - Country:US
Practice Address - Phone:646-586-9908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12869363A00000X
MAPA100237363A00000X
AZ9042363A00000X
TXPA17043363A00000X
NY028296363A00000X
WAPA61433652363A00000X
MDC08341363A00000X
GA11549363A00000X
COPA.0007864363A00000X
CA53299363A00000X
SC4698363A00000X
VA0110003132363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant