MEDICARE: LOTTIE J DAVIS RN, BSN, IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WL0100X	Lactation Consultant (Registered Nurse)	9529219	FL

General Provider Information

NPI Number	:	1205659257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOTTIE J DAVIS RN, BSN, IBCLC

Provider Business Mailing Address
First Line	:	78 KREWE CIR
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-6821
Country	:	US
Telephone Number	:	850-895-9922
Fax Number	:

Provider Business Practice Location Address
First Line	:	78 KREWE CIR
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-6821
Country	:	US
Telephone Number	:	850-895-9922
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2024
Last Update Date	:	11/06/2024

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