Provider Demographics
NPI:1700862406
Name:MYKLEBY, CONNIE COLLEEN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:COLLEEN
Last Name:MYKLEBY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-0021
Mailing Address - Country:US
Mailing Address - Phone:563-324-8160
Mailing Address - Fax:563-324-8486
Practice Address - Street 1:1227 EAST RUSHOLME STREET
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2498
Practice Address - Country:US
Practice Address - Phone:563-421-1000
Practice Address - Fax:563-421-7889
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA062389367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1119479Medicaid
IA1119479Medicaid
57873Medicare ID - Type Unspecified