The familiar three-color map of full, reduced and restricted practice is published by a nurse practitioner trade association as advocacy, not law. It is a reasonable starting index and a poor operating document. What actually constrains a clinic is the specific numbers in each state’s statute: how many advanced practice clinicians one physician may cover, what share of charts must be reviewed and how often, how far apart the offices may sit, and whether your service line is carved out.
What the three categories actually are
The association defines full practice as state law permitting all NPs to evaluate, diagnose, order tests, and initiate and manage treatments, including prescribing, “under the exclusive licensure authority of the state board of nursing.” Reduced and restricted describe states that require a career-long regulated relationship with another health profession.
Those definitions are useful. The map is stamped May 2026 and already lags the statutes: Wisconsin’s independence law took effect September 1, 2026, which is after the map was drawn. Use the map to orient, then read the statute for the state you are actually opening in.
The numbers you staff around
For the nine states where we publish state pages, these are the operating constraints, not the color.
| State | Physician relationship | The numbers that bind |
|---|---|---|
| Arizona | None required | No ratio, no protocol, no chart review in the statute |
| New York | None above 3,600 hours | Below that: chart review at least every three months; a physician may hold agreements with no more than four NPs not on the same premises. A parallel version requiring collaborative relationships takes effect July 1, 2030 |
| Texas | Always. Prescriptive authority agreement | Seven advanced practice clinicians and physician assistants combined per physician; documented meetings at least monthly; agreement reviewed annually. No chart review percentage in law |
| Georgia | Always. Nurse protocol agreement, filed with the board within 30 days | Eight combined per physician; 100 percent of controlled substance records reviewed at least quarterly; 10 percent of other records annually; onsite observation at least annually; physician within 50 miles |
| Tennessee | Always. Supervising physician and written protocols | At least 20 percent of charts reviewed every 30 days; a remote site visit every 30 days; personal review within 10 business days when a controlled drug is prescribed |
| Illinois | Until full practice authority | 4,000 clinical hours plus 250 hours of continuing education. Before that, Schedule II is limited and requires monthly discussion of each patient |
| California | Always, in some form | No physician may supervise more than four NPs at one time. The transition pathway is 4,600 hours, then three further years for the setting-independent category |
| Florida | Yes, unless autonomous | Autonomous registration takes 3,000 clinical hours in the prior five years, and is limited to primary care practice |
| New Jersey | Yes, unless exempt | The exemption takes more than 5,000 hours, and excludes aesthetics. See below |
Two of these surprise operators. Texas sets no chart review percentage at all: the parties pick the number. What binds in Texas is the seven-person cap and the monthly documented meeting. And Missouri, outside our nine, is the tightest we read on geography: 10 percent of charts every 14 days, 20 percent where controlled substances are prescribed, a physician on site at least every two weeks, and a maximum of six full-time equivalents.
Three states put aesthetics in writing
This is the part a med spa owner needs, and it is where the general map is most misleading.
New Jersey wrote it into the statute this year. The 2026 amendment creates a pathway to practice without a joint protocol, but the qualifying clinician must have more than 5,000 hours providing primary or behavioral health care and must be “not providing elective aesthetic or cosmetic services.” An NP running an aesthetics practice in New Jersey does not reach the exemption, and still needs a joint protocol. Anyone describing New Jersey as having loosened up for med spas has read the headline and not the carve-out.
Texas treats the procedures themselves as the practice of medicine. The Medical Board’s nonsurgical cosmetic procedure rules put the delegation question at the center, and the Board of Nursing’s own guidance says advanced practice nurses do not have independent authority for these procedures and act by delegation. If you are hiring a Texas medical director, this is why the physician cannot be a figurehead.
Florida’s autonomous pathway is real but narrow. Autonomous registration is limited to “primary care practice,” and the board rule defining that term contains no cosmetic or elective language. An autonomous APRN running a med spa in Florida is relying on a reading of that definition that nothing has tested. Florida separately sets the most specific aesthetic supervision rule we found: an off-site supervising physician for a primarily dermatologic or aesthetic office must be board certified or board eligible in dermatology or plastic surgery, may supervise only one additional office, and must be within 25 miles.
Independence is almost never immediate
Every pathway we verified has a runway measured in thousands of hours or years:
- Florida, 3,000 hours in the prior five years
- New York, 3,600 hours
- Wisconsin, 3,840 hours of nursing plus 3,840 as an APRN, with at least 24 months elapsed
- Illinois, 4,000 clinical hours plus 250 hours of continuing education
- California, 4,600 hours, then three more years for the setting-independent category
- New Jersey, more than 5,000 hours, aesthetics excluded
- Arkansas and Oklahoma, 6,240 hours
- Virginia, the equivalent of three years full time
- Kentucky, four years of prescribing to exit each of its two agreement types
Arizona is the outlier among our nine: independent on certification, with nothing in the statute to staff around.
What moved recently, and what did not
Four changes are recent enough that most published summaries are behind:
- Wisconsin. The APRN Modernization Act was enacted August 8, 2025 and took effect September 1, 2026. It is in force now.
- Oklahoma. Independent prescriptive authority after 6,240 hours was enacted over a veto, with the override on May 29, 2025 and an effective date of November 1, 2025.
- Kentucky. The agreement framework was amended again, effective April 10, 2026. Anything citing the 2023 or 2024 version is a version behind.
- New Jersey. The 2026 amendment described above, approved March 30, 2026.
Two widely expected changes did not happen, and operators plan around them at their peril. North Carolina’s independence bills have sat in committee since March 2025. Pennsylvania’s full practice bill was referred to committee in January 2025 and never moved. Texas saw two full practice bills left pending in committee in 2025.
The compact will not solve this
The APRN Compact would give a multistate license, but it becomes effective only “when Compact has been enacted into law in seven (7) party states,” and it is not operational. The most recent enactment announcement we could verify from the nursing regulators themselves named a fourth state in February 2024. We could not verify a current count anywhere on their site, so we will not print one. If a vendor quotes you a number, ask for the source.
Note also what the compact would and would not do. It addresses licensure mobility. It would not change any state’s collaboration requirement, ratio or chart review rule. That is the same lesson as the physician compact.
What this means for you
Do not staff from the color map. For each state you operate in, write down four numbers: how many advanced practice clinicians your physician may cover, what percentage of charts must be reviewed and on what clock, how often a meeting or site visit is required, and any distance limit. Those numbers decide how many physicians you actually need, and they are the first thing a board asks for. Then check whether your service line is carved out, because in New Jersey, Texas and Florida aesthetics is treated differently from primary care. If the answer is that an NP cannot carry the clinical authority alone in your state, that is not a workaround problem, it is a medical director question, and the good faith exam rules sit on top of it for every med spa treatment you sell.
Related reading
Frequently asked questions
Which states allow nurse practitioners full practice authority?
The nurse practitioner association’s May 2026 map counts 28 states plus the District of Columbia as full practice, but that is a trade classification rather than law, and it already lags: Wisconsin’s independence statute took effect September 1, 2026. Read the state’s own statute, because several “full practice” states still impose a transition period of thousands of hours.
Does a nurse practitioner need a collaborating physician?
It depends on the state and often on experience. Arizona requires no relationship. New York requires one only below 3,600 practice hours. Texas, Georgia, Tennessee, California and Pennsylvania require one indefinitely or nearly so, each with its own ratio, chart review and meeting requirements written into statute or rule.
Can a nurse practitioner do Botox without a physician?
In several states, no. Texas treats nonsurgical cosmetic procedures as the practice of medicine requiring delegation, and its nursing board says advanced practice nurses lack independent authority for them. New Jersey’s 2026 independence pathway expressly excludes elective aesthetic or cosmetic services. Florida’s autonomous pathway is limited to primary care practice.
How many nurse practitioners can one physician supervise?
It varies and it is usually a hard number. Texas allows seven advanced practice clinicians and physician assistants combined. Georgia allows eight combined. California allows four nurse practitioners at one time. New York limits a physician to four nurse practitioners not on the same premises. Missouri caps six full-time equivalents.
Is the APRN Compact in effect?
No. Its own terms make it effective only when seven states have enacted it, and the nursing regulators’ site describes it prospectively rather than as operating. The most recent enactment announcement we could verify named a fourth state in February 2024. No current enacting count is published, so treat any number you are quoted as unverified.
This is general information, not legal advice. Rules vary by state and change. Confirm your own facts with counsel.