Basic Information
| Provider Information | |||||||||
| NPI: | 1104541150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | RIKI | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 906 S 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657219315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178809481 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1235 E CHEROKEE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178202000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2022 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2014029277 | MO | Y | Nursing Service Providers | Registered Nurse |
No ID Information.