| Name | Value |
|---|---|
| PROVIDER TYPE | Nursing Service |
| CLASSIFICATION | Nurse Practitioner |
| AREA OF SPECIALIZATION | Family Nurse Practitioner |
| STATUS | Inactive |
| DATE INACTIVATED | 1998-10-20 00:00:00 |
| VA CODE | V070502 |
| reserved | P663 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252816 |
| EFFECTIVE DATE/TIME |
|