Provider Demographics
NPI:1275874125
Name:FACKRELL, ALEXANDRA (OTR)
Entity Type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:
Last Name:FACKRELL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 CLEARFIELD AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3383
Mailing Address - Fax:757-321-3332
Practice Address - Street 1:1975 GLENN MITCHELL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456
Practice Address - Country:US
Practice Address - Phone:757-368-3284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119001621225XH1200X, 286500000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No286500000XHospitalsMilitary Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAMEDICARE GROUPOtherC05501