Get GA Delegating Advanced Practice Registered Nurse (APRN) Protocol Agreement Information 2014-2023
FIRST NAME GEORGIA LICENSE NUMBER __________________________ DEA REGISTRATION NUMBER MIDDLE NAME Please check, if the delegating physician is a: ____Georgia state employee ____Georgia county employee ____Georgia city employee If you checked any of the boxes above, please submit proof of employment. DEGREE: (MD OR DO) PRACTICE DESCRIPTION AND SPECIALTY AREA: _____________________________________________________________ # OF LOCATIONS- TO INCLUDE SATELLITE SITE(S): PRACTICE ADDRESS WHERE AP.
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