License Verification - VI Department of Health

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License Verification

Home » Office of Professional Licensure and Health Planning » License Verification

Verification Request Form

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Name

First

Last

Email

Licensee / Facility Name

License Type

License Number

(If Applicable)

Name

Contact Person

Agency

Email Address

Billing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Credit Card

Card Number

Expiration

/

Security Code

Fee

Price: $10.00

Total

$0.00