Provider Demographics
NPI:1114676566
Name:RISNER, MICAELA CHEYENNE
Entity Type:Individual
Prefix:MISS
First Name:MICAELA
Middle Name:CHEYENNE
Last Name:RISNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8130 OHIO RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-1625
Mailing Address - Country:US
Mailing Address - Phone:740-574-5054
Mailing Address - Fax:740-574-8924
Practice Address - Street 1:8130 OHIO RIVER RD
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1625
Practice Address - Country:US
Practice Address - Phone:740-574-5054
Practice Address - Fax:740-574-8924
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09216285183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician