Provider Demographics
NPI:1225120173
Name:DEFRAIN, MARYLEE (CRNP)
Entity Type:Individual
Prefix:
First Name:MARYLEE
Middle Name:
Last Name:DEFRAIN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HOSPITAL AVE
Mailing Address - Street 2:SUITE 113
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1462
Mailing Address - Country:US
Mailing Address - Phone:814-375-3722
Mailing Address - Fax:814-375-3086
Practice Address - Street 1:145 HOSPITAL AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1462
Practice Address - Country:US
Practice Address - Phone:814-375-3722
Practice Address - Fax:814-375-3086
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007583363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0655941Medicare ID - Type Unspecified
P76879Medicare UPIN