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Get GA Delegating Advanced Practice Registered Nurse (APRN) Protocol Agreement Information 2009

TERED NURSE (APRN) PROTOCOL AGREEMENT INFORMATION DELEGATING PHYSICIAN INFORMATION LAST NAME FIRST NAME GEORGIA LICENSE NUMBER __________________________ DEA REGISTRATION NUMBER __________________________ MIDDLE NAME Please check, if any apply. Are you a: ____Georgia state employee ____Georgia county employee ____Georgia city employee If you checked any of the boxes above, please submit proof of employment, e.g. W2, 1099, paycheck stub DEGREE: (MD OR DO) PRACTICE DESCRIPTION: _____________.

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