Basic Information
| Provider Information | |||||||||
| NPI: | 1265490064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITHERRITE | ||||||||
| FirstName: | LIETTE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POWELL | ||||||||
| OtherFirstName: | LIETTE | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1519 | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986721519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094932133 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 212 NE SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986721948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094932133 | ||||||||
| FaxNumber: | 5094939538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 07/23/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00046452 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 938227 | 05 | AZ | MEDICAID |