Provider Demographics
NPI:1982476305
Name:BRENTZEL, SHELLY ELISE (NP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ELISE
Last Name:BRENTZEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7129 SALERNO ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3413
Mailing Address - Country:US
Mailing Address - Phone:410-353-1447
Mailing Address - Fax:
Practice Address - Street 1:12301 WILSHIRE BLVD STE 512
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1053
Practice Address - Country:US
Practice Address - Phone:888-684-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95132333163W00000X
CA95026831363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse