Healthcare Provider Details

I. General information

NPI: 1104541150
Provider Name (Legal Business Name): RIKI LEE CLARK PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 S WAVERLY AVE STE 500
SPRINGFIELD MO
65804-2400
US

IV. Provider business mailing address

396 MAYNARD RD
NIXA MO
65714-7267
US

V. Phone/Fax

Practice location:
  • Phone: 417-880-9481
  • Fax:
Mailing address:
  • Phone: 417-880-9481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2022042624
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2014029277
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: