Provider Demographics
NPI:1225009376
Name:KECK, VICKI J (FNP)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:J
Last Name:KECK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-906-4623
Mailing Address - Fax:619-906-4564
Practice Address - Street 1:2401 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-4619
Practice Address - Country:US
Practice Address - Phone:816-234-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004107363LF0000X
MO151601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428972202Medicaid
MO428972202Medicaid
KS0447460003Medicare NSC
KS115C400AMedicare PIN