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Get Individual SAFE Examiner Application - New York State Department ... - Health Ny

Ess Street Telephone # ( Apt. # ) State E-mail - of Applicant Fax Name # ( ) Date of Birth/Social Security No. of Applicant? Applicant Type: (check only one) City County(ies) of Practice Registered Nurse Physician Nurse Practitioner Physician Assistant License Number: IAFN SANE-A certified check if yes Application Information Type of Certification Requested: Initial Re-certification Applications will be accepted only if the application and ALL required documentation is comple.

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