Provider Demographics
NPI:1972132090
Name:REXO, ALISSA S
Entity type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:S
Last Name:REXO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25251 BEACH PLACE
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152
Mailing Address - Country:US
Mailing Address - Phone:703-473-4116
Mailing Address - Fax:
Practice Address - Street 1:25251 BEACH PLACE
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152
Practice Address - Country:US
Practice Address - Phone:703-473-4116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD6530174400000X
VA0301201746174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist