Healthcare Provider Details

I. General information

NPI: 1972306892
Provider Name (Legal Business Name): HANNAH WALLECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 25TH AVE S STE 300
MINNEAPOLIS MN
55454-1443
US

IV. Provider business mailing address

701 25TH AVE S STE 300
MINNEAPOLIS MN
55454-1443
US

V. Phone/Fax

Practice location:
  • Phone: 855-324-7843
  • Fax:
Mailing address:
  • Phone: 855-324-7843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4065
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: