MEDICARE: MRS. SANDRA MARIA DAVIS HATHAWAY 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)	11141184	CA

General Provider Information

NPI Number	:	1720350614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA MARIA DAVIS HATHAWAY IBCLC

Provider Business Mailing Address
First Line	:	1078 E 72ND ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-1035
Country	:	US
Telephone Number	:	562-674-8500
Fax Number	:	562-422-7888

Provider Business Practice Location Address
First Line	:	705 E ARTESIA BLVD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-1439
Country	:	US
Telephone Number	:	562-674-8500
Fax Number	:

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

Provider Enumeration Date	:	02/07/2012
Last Update Date	:	02/07/2012

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