Provider Demographics
NPI:1558936955
Name:RISLEY, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:RISLEY
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 1:734 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:RENOVO
Mailing Address - State:PA
Mailing Address - Zip Code:17764-1308
Mailing Address - Country:US
Mailing Address - Phone:570-502-1172
Mailing Address - Fax:
Practice Address - Street 1:6 MILLBROOK PLZ
Practice Address - Street 2:
Practice Address - City:MILL HALL
Practice Address - State:PA
Practice Address - Zip Code:17751-1911
Practice Address - Country:US
Practice Address - Phone:570-748-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician