Provider Demographics
NPI:1265490064
Name:WITHERRITE, LIETTE C (MD)
Entity Type:Individual
Prefix:
First Name:LIETTE
Middle Name:C
Last Name:WITHERRITE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LIETTE
Other - Middle Name:C
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1519
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-1519
Mailing Address - Country:US
Mailing Address - Phone:509-493-2133
Mailing Address - Fax:
Practice Address - Street 1:212 NE SKYLINE DR
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-1948
Practice Address - Country:US
Practice Address - Phone:509-493-2133
Practice Address - Fax:509-493-9538
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ938227Medicaid
103590Medicare ID - Type Unspecified
AZ938227Medicaid