Provider Demographics
NPI:1275204273
Name:HA, LILY JIEUN
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:JIEUN
Last Name:HA
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 1:7 EXECUTIVE PARK DR NE APT 2008
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2267
Mailing Address - Country:US
Mailing Address - Phone:678-360-7122
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3050
Practice Address - Country:US
Practice Address - Phone:404-778-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA11475363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program