Provider Demographics
NPI:1104541150
Name:CLARK, RIKI LEE (PMHNP)
Entity type:Individual
Prefix:
First Name:RIKI
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 MAYNARD RD
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-7267
Mailing Address - Country:US
Mailing Address - Phone:417-880-9481
Mailing Address - Fax:
Practice Address - Street 1:1675 E SEMINOLE ST STE A1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2454
Practice Address - Country:US
Practice Address - Phone:417-557-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014029277163W00000X
MO2022042624363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse