License and Registration Information
CredentialLicense TypeOriginal IssueIssue DateExpiration DateStatusDisciplineHow issuedDescription
COA.11487-NP Certified Nurse Practitioner 05/20/2010 09/30/2014 08/31/2015 INACTIVE
CTP.11487- Prescriptive Authority 06/15/2011 09/30/2014 08/31/2015 INACTIVE
CTP.11487-EX1 Prescriptive Authority - Externship 07/13/2010 06/15/2011 07/13/2011 CLOSED
PN.116753-MEDS Licensed Practical Nurse - MEDS 10/05/2004 06/05/2006 08/31/2008 INACTIVE Examination
RN.336688-1 Registered Nurse-1 Certificate of Authority 09/14/2007 09/30/2014 08/31/2015 INACTIVE Examination
License and Registration Information (cont.)
CredentialSpecialty 1Certifying Org 1Certifying ExpDate 1Specialty 2Certifying Org 2Certifying ExpDate 2Specialty 3Certifying Org 3Certifying ExpDate 3
COA.11487-NPNP - ADULTANCC4/5/2015
Effective February 1, 2011, the Board will require primary source verification for advanced practice nurse national recertification. For this to occur, an advanced practice nurse must request that their national certifying organization notify the Board directly of national recertification within thirty days of their recertification. The Board will no longer accept documentation of recertification directly from a COA holder.



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