| Name | Value |
|---|---|
| PROVIDER TYPE | Physician Assistants & Advanced Practice Nursing |
| CLASSIFICATION | Clinical Nurse Specialist |
| AREA OF SPECIALIZATION | Neonatal, High-Risk |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V100316 |
| X12 CODE | 364SN0004N |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253329 |
| EFFECTIVE DATE/TIME |
|