Healthcare Provider Details

I. General information

NPI: 1407591472
Provider Name (Legal Business Name): TATYANA GUDISHVILI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22300 NE 58TH ST
VANCOUVER WA
98682-9046
US

IV. Provider business mailing address

22300 NE 58TH ST
VANCOUVER WA
98682-9046
US

V. Phone/Fax

Practice location:
  • Phone: 360-852-3884
  • Fax: 360-558-7996
Mailing address:
  • Phone: 360-852-3884
  • Fax: 360-558-7996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00149858
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number754775
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: