Healthcare Provider Details

I. General information

NPI: 1639917842
Provider Name (Legal Business Name): BRENT ALLEN EDWARDS PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2024
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 S EL CAMINO REAL STE 200
OCEANSIDE CA
92054-6210
US

IV. Provider business mailing address

2122 S EL CAMINO REAL STE 200
OCEANSIDE CA
92054-6210
US

V. Phone/Fax

Practice location:
  • Phone: 619-267-9257
  • Fax: 619-267-9273
Mailing address:
  • Phone: 619-267-9257
  • Fax: 619-986-2656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95023840
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95040585
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number408625
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: