Healthcare Provider Details

I. General information

NPI: 1720410327
Provider Name (Legal Business Name): MARTHA Y RIDLEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARTHA RIDLEY DEMPEWOLF APRN

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 N ELM ST STE 201
HENDERSON KY
42420-2767
US

IV. Provider business mailing address

1305 N ELM ST MEDICAL STAFF OFFICE
HENDERSON KY
42420-2783
US

V. Phone/Fax

Practice location:
  • Phone: 270-827-8662
  • Fax: 270-826-8220
Mailing address:
  • Phone: 270-631-2412
  • Fax: 270-827-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1117672
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3008270
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: