Healthcare Provider Details

I. General information

NPI: 1083300248
Provider Name (Legal Business Name): ALEXANDRA GRACE OTWELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST # 520
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

4206 VALLEY VIEW DR
LITTLE ROCK AR
72212-2067
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-6627
  • Fax:
Mailing address:
  • Phone: 501-350-6808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: