Basic Information
| Provider Information | |||||||||
| NPI: | 1720347933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIDENOUR | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | F.N.P., BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6810 STATE ROUTE 162 STE 215 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183916410 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 N FIRST ST MEMORIAL HEALTH SYSTEM | ||||||||
| Address2: | MIDWEST EMERGENCY DEPT SPECIALISTS | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627810001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184987108 | ||||||||
| FaxNumber: | 6184987919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2012 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 209009534 | IL | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 209009534 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 209009534 | 05 | IL | MEDICAID |