=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124819040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HATTIE MCLANE DAVIS BSN RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2025
-----------------------------------------------------
Last Update Date | 05/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4605 MACCORKLE AVE SW
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-766-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 465 SILVER MAPLE RDG APT 9
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25306-1153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-932-7576
-----------------------------------------------------
Fax | 304-932-7576
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 109766
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------