Provider Demographics
NPI:1982902888
Name:LUTTRELL, TIFFANY DAWN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:DAWN
Last Name:LUTTRELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:DAWN
Other - Last Name:REAGOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-606-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX652703163W00000X
TXAP120053367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX291790YQ8AOtherMEDICARE
TX75-2771569-008OtherTRICARE
TX8512UEOtherBCBS
TXP01877246OtherMEDICARE RAIL ROAD
TX75-0818167-015OtherTRICARE
TX280097104Medicaid
TX280097105Medicaid
TXP01196965OtherRAIL ROAD
TX291790YN3XOtherMEDICARE
TX8512UEOtherBCBS BLUE
TXP01196965OtherMCRR