Provider Demographics
NPI:1558591362
Name:GRAY, TIFFANY RADFORD (CRNA)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:RADFORD
Last Name:GRAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:E
Other - Last Name:RADFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:6211 WRIGHTSVILLE AVE APT 121
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3861
Mailing Address - Country:US
Mailing Address - Phone:252-241-2087
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401
Practice Address - Country:US
Practice Address - Phone:910-343-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC082167367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered