Provider Demographics
NPI:1063807238
Name:LIPPERT, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:LIPPERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 MDG/SGHJ
Mailing Address - Street 2:4881 SUGAR MAPLE DR
Mailing Address - City:WRIGHT PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-257-9655
Mailing Address - Fax:
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:CHE 7TH FLOOR
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-2485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.131068207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine