Provider Demographics
NPI:1811460769
Name:GRANATELLI, LACE (PA-C)
Entity type:Individual
Prefix:
First Name:LACE
Middle Name:
Last Name:GRANATELLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 VIA CANTILENA
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-0926
Mailing Address - Country:US
Mailing Address - Phone:805-816-4473
Mailing Address - Fax:
Practice Address - Street 1:2831 N VENTURA RD
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2213
Practice Address - Country:US
Practice Address - Phone:805-816-4473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty