Healthcare Provider Details

I. General information

NPI: 1306553789
Provider Name (Legal Business Name): LILLIAN ELAINE GARRISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LILLIAN ELAINE HAERR

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD STE 2100
KETTERING OH
45429-1221
US

IV. Provider business mailing address

3535 SOUTHERN BLVD STE 2100
KETTERING OH
45429-1221
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-4331
  • Fax:
Mailing address:
  • Phone: 937-572-7297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007891RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberAPP-000646319
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: