Provider Demographics
NPI:1356905368
Name:ELMER, LILY
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:ELMER
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 1:2501 E 2ND ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2162
Mailing Address - Country:US
Mailing Address - Phone:971-237-1519
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLESON RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6876
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program