Provider Demographics
NPI:1801652367
Name:FACKRELL, LILLIAN NICOLE (DC)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:NICOLE
Last Name:FACKRELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 S TAMARAK CIR
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2761
Mailing Address - Country:US
Mailing Address - Phone:816-419-6513
Mailing Address - Fax:
Practice Address - Street 1:6717 S 900 E STE 101
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-5755
Practice Address - Country:US
Practice Address - Phone:801-784-8886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13763325111N00000X
UT13763325-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor