Healthcare Provider Details

I. General information

NPI: 1831821420
Provider Name (Legal Business Name): RILEY NICOLE MCKUIN PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RILEY NICOLE GREENWALL PMHNP-BC

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 OAK GROVE RD
POPLAR BLUFF MO
63901-1573
US

IV. Provider business mailing address

210 RUTH HARRIS LN
POPLAR BLUFF MO
63901-2206
US

V. Phone/Fax

Practice location:
  • Phone: 573-776-2000
  • Fax: 573-686-8210
Mailing address:
  • Phone: 573-300-8117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2022010858
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2022028517
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2018021822
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: