| Name | Value |
|---|---|
| PROVIDER TYPE | Nursing Service Providers |
| CLASSIFICATION | Registered Nurse |
| AREA OF SPECIALIZATION | College Health |
| STATUS | Active |
| VA CODE | V070906 |
| X12 CODE | 163WC1400X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252879 |
| EFFECTIVE DATE/TIME |
|