Provider Demographics
NPI:1114097615
Name:RAY, TIFFANY SHANNON (CRNA)
Entity Type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:SHANNON
Last Name:RAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 WALNUT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-2023
Mailing Address - Country:US
Mailing Address - Phone:901-652-0880
Mailing Address - Fax:
Practice Address - Street 1:6410 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-2023
Practice Address - Country:US
Practice Address - Phone:901-652-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864509367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered