Provider Demographics
NPI:1720347933
Name:RIDENOUR, KAREN L (FNP, BC)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:L
Last Name:RIDENOUR
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162 STE 215
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8566
Mailing Address - Country:US
Mailing Address - Phone:618-391-6410
Mailing Address - Fax:
Practice Address - Street 1:701 N FIRST ST MEMORIAL HEALTH SYSTEM
Practice Address - Street 2:MIDWEST EMERGENCY DEPT SPECIALISTS
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:618-498-7108
Practice Address - Fax:618-498-7919
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009534163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209009534Medicaid
IL163W00000XOtherTAXONOMY