Provider Demographics
NPI:1407591472
Name:GUDISHVILI, TATYANA (RN)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:GUDISHVILI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22300 NE 58TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-9046
Mailing Address - Country:US
Mailing Address - Phone:360-852-3884
Mailing Address - Fax:360-558-7996
Practice Address - Street 1:22300 NE 58TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-9046
Practice Address - Country:US
Practice Address - Phone:360-852-3884
Practice Address - Fax:360-558-7996
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00149858163W00000X
WA754775311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No163W00000XNursing Service ProvidersRegistered Nurse