Provider Demographics
NPI:1972226330
Name:LOVELACE, TIMOTHY R (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:LOVELACE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 HAYWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-4730
Mailing Address - Country:US
Mailing Address - Phone:501-960-4911
Mailing Address - Fax:
Practice Address - Street 1:2400 N INTERSTATE HIGHWAY 35 E
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5240
Practice Address - Country:US
Practice Address - Phone:469-843-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1096032367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered