Healthcare Provider Details

I. General information

NPI: 1124819040
Provider Name (Legal Business Name): HATTIE MCLANE DAVIS BSN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MACCORKLE AVE SW
CHARLESTON WV
25309-1311
US

IV. Provider business mailing address

465 SILVER MAPLE RDG APT 9
CHARLESTON WV
25306-1153
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-3600
  • Fax:
Mailing address:
  • Phone: 304-932-7576
  • Fax: 304-932-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number109766
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: