Healthcare Provider Details

I. General information

NPI: 1518778976
Provider Name (Legal Business Name): ELIJAH RYAN PHOENIX PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S HICKORY ST STE 114
ESCONDIDO CA
92025-4360
US

IV. Provider business mailing address

9951 HOLDER ST APT 49
CYPRESS CA
90630-4009
US

V. Phone/Fax

Practice location:
  • Phone: 866-905-9410
  • Fax:
Mailing address:
  • Phone: 618-919-0972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95232470
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95032063
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: