Healthcare Provider Details

I. General information

NPI: 1568181022
Provider Name (Legal Business Name): EDGAR RODOLFO BENAVIDEZ RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 E PALMDALE BLVD
PALMDALE CA
93550-4786
US

IV. Provider business mailing address

43361 GADSDEN AVE APT 330
LANCASTER CA
93534-6139
US

V. Phone/Fax

Practice location:
  • Phone: 661-996-1051
  • Fax: 661-347-2319
Mailing address:
  • Phone: 661-537-5932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95038959
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: