NURSE PRACTITIONER LICENSE VERIFICATION FORM
9960 Mayland Drive Suite 300 Perimeter Center Henrico, Virginia 23233 (804) 367-4515 dhp.nursing
NURSE PRACTITIONER LICENSE VERIFICATION FORM
TO THE APPLICANT ? Complete the top portion only and send to the Board of Nursing in the state where you were originally licensed as a nurse practitioner (fee may be required).
Name:
Last
First:
Middle:
Social Security Number:
Address: Nurse Practitioner License No.: Name on Original License:
Year Issued:
TO THE BOARD OF NURSING: Please provide the information requested and return the form to the Virginia Board of Nursing APPLICANT'S FULL NAME:
Last:
First :
Middle:
Maiden:
Name of Master's/Graduate Degree Program: Program Completion Date:
City, State or Province:
Type of Program:
MSN
Post
Master's
Other:_____________________
Length of Program:
Master's/Graduate Degree Program Accredited/Approved By: (Accrediting Authority):
LICENSE NUMBER ___________________ was granted on ____________________ by: Examination Endorsement Waiver
Status of license: Current Lapsed Inactive
Has license ever been suspended, revoked or otherwise disciplined? Yes Board.
No . If yes, please attach certified copy of any order issued by the
I certify the above information to be true in every respect, according to the record on file with the _________________ State Board of Nursing.
____________________________ Date
_______________________________________________ Executive Director
Revised: 5/1/18
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