MEDICARE: MS. SHERLENE CLARK DEAN APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0807X	Child & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist	204333-4405	UT

General Provider Information

NPI Number	:	1871603860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHERLENE CLARK DEAN APRN

Provider Business Mailing Address
First Line	:	PO BOX 413076
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84141-3076
Country	:	US
Telephone Number	:	801-213-3900
Fax Number	:	801-585-3655

Provider Business Practice Location Address
First Line	:	650 S KOMAS DR STE 208
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84108-1241
Country	:	US
Telephone Number	:	801-585-1212
Fax Number	:	801-585-9096

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	06/26/2014

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