License and Registration Information
CredentialLicense TypeOriginal IssueIssue DateExpiration DateStatusDisciplineHow issuedDescription
COA.01476-NS Clinical Nurse Specialist 08/20/1997 07/06/2009 08/31/2011 LAPSED
COA.06774-NP Certified Nurse Practitioner 12/13/2001 05/05/2011 08/31/2013 INACTIVE
CTP.06774-EX1 Prescriptive Authority - Externship 01/08/2004 01/08/2004 01/08/2005 LAPSED
CTP.06774- Prescriptive Authority 03/31/2005 05/05/2011 08/31/2013 INACTIVE
RN.174363-1 Registered Nurse-1 Certificate of Authority 09/11/1981 05/05/2011 08/31/2013 INACTIVE (Unknown)
License and Registration Information (cont.)
CredentialSpecialty 1Certifying Org 1Certifying ExpDate 1Specialty 2Certifying Org 2Certifying ExpDate 2Specialty 3Certifying Org 3Certifying ExpDate 3
COA.06774-NPNP - Pediatric Primary CarePNCB2/28/2014
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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