Healthcare Provider Details

I. General information

NPI: 1205436052
Provider Name (Legal Business Name): PENNY ANN LIEBBE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 17TH ST
ROCK ISLAND IL
61201-5351
US

IV. Provider business mailing address

20820 257TH AVE
LE CLAIRE IA
52753-9708
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-5000
  • Fax:
Mailing address:
  • Phone: 563-320-0149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG161048
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG161048
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: