Provider Demographics
NPI:1619742160
Name:BABCOCK, ALISSA GAIL (AGNP-C)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:GAIL
Last Name:BABCOCK
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:GAIL
Other - Last Name:WILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6054 VERMILION LOOP
Mailing Address - Street 2:
Mailing Address - City:GRANITEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29829-3258
Mailing Address - Country:US
Mailing Address - Phone:910-964-3669
Mailing Address - Fax:
Practice Address - Street 1:1200 TALISMAN DR
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-4032
Practice Address - Country:US
Practice Address - Phone:910-964-3669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC265501163W00000X
SC28302363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse