Provider Demographics
NPI:1306553789
Name:HAERR, LILLIAN ELAINE
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:ELAINE
Last Name:HAERR
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 1:1320 CAMP HILL WAY APT 9
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-3141
Mailing Address - Country:US
Mailing Address - Phone:937-572-7297
Mailing Address - Fax:
Practice Address - Street 1:3535 SOUTHERN BLVD STE 2100
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-298-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-0006463192086S0127X
OH50.007891RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery