Provider Demographics
NPI:1356176671
Name:BABCOCK, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BABCOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 TEKAMAH LN
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-6245
Mailing Address - Country:US
Mailing Address - Phone:951-234-4364
Mailing Address - Fax:
Practice Address - Street 1:1720 N 16TH ST STE K
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-0109
Practice Address - Country:US
Practice Address - Phone:712-256-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG180967363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health