Provider Demographics
NPI:1558334656
Name:VICUNA KEADY, CECILIA M (ARNP)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:M
Last Name:VICUNA KEADY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03603-0093
Mailing Address - Country:US
Mailing Address - Phone:603-826-3434
Mailing Address - Fax:603-769-3406
Practice Address - Street 1:157 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:NH
Practice Address - Zip Code:03603
Practice Address - Country:US
Practice Address - Phone:603-863-4100
Practice Address - Fax:603-526-5085
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0525322303207Q00000X
VT1010030222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010552Medicaid
NHNP4554Medicare ID - Type Unspecified
VT1010552Medicaid