Provider Demographics
NPI:1518778976
Name:PHOENIX, ELIJAH RYAN (PMHNP)
Entity type:Individual
Prefix:MR
First Name:ELIJAH
Middle Name:RYAN
Last Name:PHOENIX
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:ALDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9951 HOLDER ST APT 49
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-4009
Mailing Address - Country:US
Mailing Address - Phone:618-919-0972
Mailing Address - Fax:
Practice Address - Street 1:1100 W STEWART DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3849
Practice Address - Country:US
Practice Address - Phone:618-919-0972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95232470163W00000X
CA95032063363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse