Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 0119001621 | VA |
N | 225XH1200X | Occupational Therapist - Hand | 0119001621 | VA |
NPI | 1275874125 |
---|---|
Provider Name | Ms. Alexandra Fackrell |
First Address | Virginia Beach, VA 23462-1832 |
Second Address | Virginia Beach, VA 23456 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/03/2013 |
Last Update Date | 23/07/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MEDICARE GROUP | C05501 (01) | VA |