Healthcare Provider Details

I. General information

NPI: 1972560779
Provider Name (Legal Business Name): LARRY D LIEB CRNA ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W MAIN ST
LAKE CITY IA
51449-1585
US

IV. Provider business mailing address

225 W RANDALL RD
CARROLL IA
51401-3601
US

V. Phone/Fax

Practice location:
  • Phone: 712-464-3171
  • Fax: 712-464-7412
Mailing address:
  • Phone: 712-792-1004
  • Fax: 712-792-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberD-059739
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: