Healthcare Provider Details

I. General information

NPI: 1104276948
Provider Name (Legal Business Name): ALICIA ANNE VANDEWALLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALICIA ANNE MAVIS APRN

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E WAYNE ST
RANDOLPH NE
68771-5300
US

IV. Provider business mailing address

PO BOX 429 402 N MAPLE
OSMOND NE
68765-0429
US

V. Phone/Fax

Practice location:
  • Phone: 402-337-0200
  • Fax:
Mailing address:
  • Phone: 402-748-3393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number112022
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: