MEDICARE: ALISSA GAIL BABCOCK AGNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	GAA-NP002092	GA
2	363L00000X	Nurse Practitioner	5023561	NC
3	363L00000X	Nurse Practitioner	28302	SC
4	163W00000X	Registered Nurse	265501	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GAA-NP002092	OTHER	GA	LICENSE

General Provider Information

NPI Number	:	1619742160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISSA GAIL BABCOCK AGNP-C

Provider Business Mailing Address
First Line	:	6054 VERMILION LOOP
Second Line	:
City	:	GRANITEVILLE
State	:	SC
Zip	:	29829-3258
Country	:	US
Telephone Number	:	910-964-3669
Fax Number	:

Provider Business Practice Location Address
First Line	:	254 FURYS FERRY RD
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30907-3118
Country	:	US
Telephone Number	:	706-986-0999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2023
Last Update Date	:	04/13/2026

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