Provider Demographics
NPI:1376216655
Name:BOIMAH, LILIAN WATTA
Entity Type:Individual
Prefix:
First Name:LILIAN
Middle Name:WATTA
Last Name:BOIMAH
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 1:4023 51ST WAY S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6080
Mailing Address - Country:US
Mailing Address - Phone:701-204-8667
Mailing Address - Fax:
Practice Address - Street 1:4023 51ST WAY S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6080
Practice Address - Country:US
Practice Address - Phone:701-204-8667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-31
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND85-1786436Medicaid