Healthcare Provider Details

I. General information

NPI: 1659965408
Provider Name (Legal Business Name): MARYLOUISE DEAVEN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 02/23/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CHURCH ST
LEBANON PA
17046-4656
US

IV. Provider business mailing address

304 N WATER ST
LANCASTER PA
17603-3374
US

V. Phone/Fax

Practice location:
  • Phone: 717-272-2700
  • Fax:
Mailing address:
  • Phone: 717-299-6371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP023311
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: