Healthcare Provider Details

I. General information

NPI: 1003730540
Provider Name (Legal Business Name): AMANDA ROSE BENVENUTO MSN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1000 QUAIL ST STE 245
NEWPORT BEACH CA
92660-2749
US

IV. Provider business mailing address

24036 CONTINENTAL DR
CANYON LAKE CA
92587-7757
US

V. Phone/Fax

Practice location:
  • Phone: 949-594-4795
  • Fax:
Mailing address:
  • Phone: 949-500-2785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95040623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: