Healthcare Provider Details

I. General information

NPI: 1104749837
Provider Name (Legal Business Name): TARA RAE GORDIJENKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 ISAAC DR
BUNKER HILL WV
25413-4267
US

IV. Provider business mailing address

210 ISAAC DR
BUNKER HILL WV
25413-4267
US

V. Phone/Fax

Practice location:
  • Phone: 681-273-9995
  • Fax: 681-227-9995
Mailing address:
  • Phone: 681-273-9995
  • Fax: 681-227-9995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP55602
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: