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ProviDRs Care Network 67211

WPPA, Inc. ProviDRs care Network 1102 S. Hillside Wichita, KS 67211 Controlled Substance Verification Form (Please Print or Type) APRN Name: _____ Kansas Certification Number: _____ Expiration Date:_____ Check your APRN Category Clinical Nurse Specialist Nurse Midwife Nurse Practitioner Attention: The Nurse anesthetist does not have statutory authority to obtain a DEA number. Attention: APRN s may choose not to participate in prescribing controlled substances. Those individuals not wishing to participate do not need to complete and submit this form. Current Business Address: _____ _____ A change in principal place of business needs to be reported within 10 days.

WPPA, Inc. ProviDRs Care Network ... MID-LEVEL PRACTITIONER CLINICAL PRACTICE GUIDELINES APPLICANT PA/APRN is to mark each procedure being requested. Column 1 may be done by PA/APRN when physician is present. Column 2 may be …

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