Provider Demographics
NPI:1285019695
Name:VICKROY, KENNETH (FNP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:VICKROY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W THOMAS RD STE 114
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4420
Mailing Address - Country:US
Mailing Address - Phone:602-406-4578
Mailing Address - Fax:602-424-5445
Practice Address - Street 1:222 W THOMAS RD STE 114
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4420
Practice Address - Country:US
Practice Address - Phone:602-406-4578
Practice Address - Fax:602-424-5445
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation