Healthcare Provider Details

I. General information

NPI: 1225524432
Provider Name (Legal Business Name): DORA DAVIS DAVIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MYSTERY MT ROAD
DELBARTON WV
25670
US

IV. Provider business mailing address

PO BOX 255
VARNEY WV
25696-0255
US

V. Phone/Fax

Practice location:
  • Phone: 304-426-8540
  • Fax:
Mailing address:
  • Phone: 304-426-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number67794
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: