Healthcare Provider Details

I. General information

NPI: 1477436277
Provider Name (Legal Business Name): TAMMA JIVIDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 MUDDYGUT RD
POCA WV
25159
US

IV. Provider business mailing address

PO BOX 116
POCA WV
25159-0116
US

V. Phone/Fax

Practice location:
  • Phone: 304-382-4352
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: