Healthcare Provider Details

I. General information

NPI: 1881387660
Provider Name (Legal Business Name): RILEY RENEE CLUBB BSN, RN, DNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RILEY RENEE SPICKERMAN BSN, RN

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 06/21/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6805 IL-162
MARYVILLE IL
62062
US

IV. Provider business mailing address

6805 IL-162
MARYVILLE IL
62062
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-5019
  • Fax:
Mailing address:
  • Phone: 618-288-5019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.454256
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209029835
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: