Provider Demographics
NPI:1710273057
Name:WITTICH, LILY J (MD)
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:J
Last Name:WITTICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LILY
Other - Middle Name:JANE
Other - Last Name:SHIPSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-706-8526
Mailing Address - Fax:509-459-0686
Practice Address - Street 1:104 W 5TH AVE
Practice Address - Street 2:SUITE 200W
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-4880
Practice Address - Country:US
Practice Address - Phone:509-624-2313
Practice Address - Fax:509-459-0686
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD60404330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program