| Name | Value |
|---|---|
| PROVIDER TYPE | Nursing Service Providers |
| CLASSIFICATION | Registered Nurse |
| AREA OF SPECIALIZATION | General Practice |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V070909 |
| X12 CODE | 163WG0000X |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252912 |
| EFFECTIVE DATE/TIME |
|