Provider Demographics
NPI:1427367010
Name:CONWAY, CICELY ANDREE (LAC)
Entity Type:Individual
Prefix:
First Name:CICELY
Middle Name:ANDREE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-7062
Mailing Address - Country:US
Mailing Address - Phone:206-412-0777
Mailing Address - Fax:
Practice Address - Street 1:18 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-7062
Practice Address - Country:US
Practice Address - Phone:206-412-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60130160172M00000X
VT091.0134002171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No172M00000XOther Service ProvidersMechanotherapist