Healthcare Provider Details

I. General information

NPI: 1316770936
Provider Name (Legal Business Name): CRYSTLE RENEE LIEBHART MEGGENBERG DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTLE R LIEBHART

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N JACKSON ST
MORRISON IL
61270-3042
US

IV. Provider business mailing address

303 N JACKSON ST
MORRISON IL
61270-3042
US

V. Phone/Fax

Practice location:
  • Phone: 815-772-4003
  • Fax:
Mailing address:
  • Phone: 815-772-4003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberH178934
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.031556
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: