Healthcare Provider Details

I. General information

NPI: 1164861753
Provider Name (Legal Business Name): ALISA NATASHA HILL-BOSTIC FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALISA NATASHA ALLICOCK FNP

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 GA HWY 57
TOWNSEND GA
31331
US

IV. Provider business mailing address

501 BURKE DRIVE APT 319
HINESVILLE GA
31313
US

V. Phone/Fax

Practice location:
  • Phone: 912-574-5277
  • Fax: 912-228-5007
Mailing address:
  • Phone: 609-504-6601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN198722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: