Healthcare Provider Details

I. General information

NPI: 1598556805
Provider Name (Legal Business Name): HANNAH ROSE WALLACE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 E DRAPER PKWY
DRAPER UT
84020-9095
US

IV. Provider business mailing address

13787 S LINDA MARIE LN
RIVERTON UT
84065-2316
US

V. Phone/Fax

Practice location:
  • Phone: 801-878-7411
  • Fax:
Mailing address:
  • Phone: 801-244-8467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number12649947-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number12649947-3102
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number12649947-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: