Basic Information
| Provider Information | |||||||||
| NPI: | 1982902888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUTTRELL | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REAGOR | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036064522 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2011 | ||||||||
| LastUpdateDate: | 11/22/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 652703 | TX | N | Nursing Service Providers | Registered Nurse | 367500000X | AP120053 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 291790YQ8A | 01 | TX | MEDICARE | OTHER | 75-2771569-008 | 01 | TX | TRICARE | OTHER | 8512UE | 01 | TX | BCBS | OTHER | P01877246 | 01 | TX | MEDICARE RAIL ROAD | OTHER | 75-0818167-015 | 01 | TX | TRICARE | OTHER | 280097104 | 05 | TX | MEDICAID | 280097105 | 05 | TX | MEDICAID | P01196965 | 01 | TX | RAIL ROAD | OTHER | 291790YN3X | 01 | TX | MEDICARE | OTHER | 8512UE | 01 | TX | BCBS BLUE | OTHER | P01196965 | 01 | TX | MCRR | OTHER |