Healthcare Provider Details

I. General information

NPI: 1891341574
Provider Name (Legal Business Name): AURELIA RENEE WANN DNP, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AURI CLARK

II. Dates (important events)

Enumeration Date: 08/17/2019
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E 9TH AVE STE 205
SALT LAKE CITY UT
84103-3184
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-408-6100
  • Fax: 801-355-9968
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number5358904-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: