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found on page 36; use license status codes. Enter 3-digit code in space provided. Code list is found on page 36; use provider type codes. Enter 3-digit code in space provided. LICENSE STATUS CODE LICENSE TYPE M M D D Y STATE LICENSE NUMBER LICENSE ISSUING STATE IF THIS IS A STATE LICENSE, ARE YOU CURRENTLY PRACTICING IN THIS STATE? YES LICENSE ISSUE DATE NO M M D D Y LICENSE EXPIRATION DATE Code list is found on page 36; use license status codes. Enter 3-digit code in space provided.

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