License and Registration Information
CredentialLicense TypeOriginal IssueIssue DateExpiration DateStatusDisciplineHow issuedDescription
COA.02204-NS Clinical Nurse Specialist 08/20/1997 08/31/2001 08/31/2003 INACTIVE
COA.03892-NP Certified Nurse Practitioner 10/27/1997 05/27/2015 08/31/2017 ACTIVE
CTP.03892- Prescriptive Authority 03/15/2002 05/27/2015 08/31/2017 ACTIVE
CTP.03892-EX1 Prescriptive Authority - Externship 03/15/2002 03/15/2002 03/15/2003 INACTIVE
CTP.03892-EX2 Prescriptive Authority - Externship Extension 03/31/2003 03/31/2003 03/15/2004 INACTIVE
RN.167261-1 Registered Nurse-1 Certificate of Authority 09/08/1980 05/27/2015 08/31/2017 ACTIVE (Unknown)
License and Registration Information (cont.)
CredentialSpecialty 1Certifying Org 1Certifying ExpDate 1Specialty 2Certifying Org 2Certifying ExpDate 2Specialty 3Certifying Org 3Certifying ExpDate 3
COA.03892-NPNP - Pediatric Primary CarePNCB2/28/2016
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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