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Click ‘Get Form’ to open the Phone:8038964550NURSEBOARDllr application in the editor.
Begin by filling out the Applicant Information section. Enter your last name, first name, middle name, suffix, mailing address, phone number, last five digits of your SSN, license number (NP, CNM or CNS), email address, and primary practice/agency details.
In the Prescriptive Authority Information section, answer whether you have an active NP, CNM or CNS license with prescriptive authority in another state. If yes, provide the necessary documentation.
Complete the Personal History Questions by responding to each question honestly. Attach written explanations for any 'Yes' answers as required.
Fill out the Supervising Physician and Alternate Supervising Physician sections with their respective details and ensure all signatures are obtained where necessary.
Finally, review all entered information for accuracy before submitting your application through our platform.
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