Provider Demographics
NPI:1447646161
Name:WALLACE, HANNAH (MD, MPH)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N HAYWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-2303
Mailing Address - Country:US
Mailing Address - Phone:727-698-3572
Mailing Address - Fax:
Practice Address - Street 1:UCLA EMERGENCY MEDICINE
Practice Address - Street 2:924 WESTWOOD BLVD, SUITE 300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-794-0585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101266944207P00000X
SCMD82212207P00000X
FLME140712207P00000X
390200000X
CAA148631207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program