Individual
MR. CHANNON LAWRENCE MCKIBBEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
300 W MAY ST, MARENGO, IA 52301-1261
(319) 642-5543
Mailing address
300 W MAY ST, MARENGO, IA 52301-1261
(319) 642-5543
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
117476
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
117476
RN LICENSE
IA
Enumeration date
04/27/2017
Last updated
07/09/2019
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