Healthcare Provider Details

I. General information

NPI: 1396491239
Provider Name (Legal Business Name): MARIAH FREEZE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAH JANE KILGUS

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6045
  • Fax:
Mailing address:
  • Phone: 570-271-6144
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP025420
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP025420
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: