| Name | Value |
|---|---|
| PROVIDER TYPE | Nursing Service |
| CLASSIFICATION | Nurse Practitioner |
| AREA OF SPECIALIZATION | Gerontological Nurse Practitioner |
| STATUS | Inactive |
| DATE INACTIVATED | 1998-10-20 00:00:00 |
| VA CODE | V070503 |
| reserved | P664 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252819 |
| EFFECTIVE DATE/TIME |
|