Alicia Anne Vandewalle, APRN
Individual provider Active NPI Family Nurse Practitioner · Randolph, NE
NPI 1104276948 · NPPES record last updated Aug 19, 2022
Key facts
- NPI
- 1104276948
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- License
- 112022 (NE)
- Practice address
- 106 E Wayne St
Randolph, NE 68771-5300 - Phone
- (402) 337-0200
- NPI assigned
- Jun 13, 2016
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 7
Hospital & facility affiliations 9
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Univ of Nebraska Medical Center, Col of Dentistry, 2016
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Osmond General Hospital Inc
Practice addresses (Care Compare)
402 N Maple St
Osmond, NE 68765-5726
Phone (402) 748-3393
Hospital & facility affiliations
- Osmond General Hospital
- Avera Sacred Heart Hospital
- Faith Health
- Colonial Manor of Randolph
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NE
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160714001396 | NE | Practitioner - Nurse Practitioner | 1658663406 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 112022 | NE | MD | Family Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Osmond General Hospital Inc | Current |
Accepting new patients | |
| Osmond General Hospital Inc | Current |
Accepting new patients | |
| Randolph Healthcare, Inc. | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | 112022 | NE | Yes |
Addresses
Primary practice location
106 E Wayne St
Randolph, NE 68771-5300
Mailing address
PO Box 429
402 N Maple
Osmond, NE 68765-0429
Phone (402) 748-3393
Other names
- Alicia Anne Mavis
Other providers in Randolph, NE
- Osmond General Hospital Inc
- Randolph Healthcare, Inc.
- Chris Arnold Rath
- Lisa Marie Rath
- Nohemi Rivera
- Mary Rose Wattier
All providers in Randolph, NE · Family Nurse Practitioner in Nebraska
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 19, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.