Provider Demographics
NPI:1942858360
Name:RISLEY, KAREN LEE
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:LEE
Last Name:RISLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:LEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1929 MIDWAY AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-3447
Mailing Address - Country:US
Mailing Address - Phone:330-956-0771
Mailing Address - Fax:
Practice Address - Street 1:1929 MIDWAY AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-3447
Practice Address - Country:US
Practice Address - Phone:333-330-9560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0212172Medicaid