Provider Demographics
NPI:1790013175
Name:FAMILY MEDICINE LIBERTY LAKE
Entity Type:Organization
Organization Name:FAMILY MEDICINE LIBERTY LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-720-4050
Mailing Address - Street 1:2207 N MOLTER RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7570
Mailing Address - Country:US
Mailing Address - Phone:509-928-6700
Mailing Address - Fax:
Practice Address - Street 1:2207 N MOLTER RD
Practice Address - Street 2:SUITE 203
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7570
Practice Address - Country:US
Practice Address - Phone:509-928-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028821207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty