Healthcare Provider Details

I. General information

NPI: 1245977040
Provider Name (Legal Business Name): HANNAH ANN WUELLNER AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 280
SAINT LOUIS MO
63128-3287
US

IV. Provider business mailing address

4932 DELOR ST
SAINT LOUIS MO
63109-2905
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-8926
  • Fax:
Mailing address:
  • Phone: 919-280-3658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2022029614
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSTUDENT
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: