Provider Demographics
NPI:1881387660
Name:CLUBB, RILEY RENEE (BSN, RN, DNP, PMHNP)
Entity type:Individual
Prefix:DR
First Name:RILEY
Middle Name:RENEE
Last Name:CLUBB
Suffix:
Gender:F
Credentials:BSN, RN, DNP, PMHNP
Other - Prefix:MS
Other - First Name:RILEY
Other - Middle Name:RENEE
Other - Last Name:SPICKERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:6805 IL-162
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-288-5019
Mailing Address - Fax:
Practice Address - Street 1:6805 IL-162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-288-5019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.454256163W00000X
IL209029835363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse