Provider Demographics
NPI:1699019281
Name:KEDDY, THERESA M (PA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:KEDDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8D CANAL CT
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3747
Mailing Address - Country:US
Mailing Address - Phone:860-674-9686
Mailing Address - Fax:
Practice Address - Street 1:8D CANAL CT
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3747
Practice Address - Country:US
Practice Address - Phone:860-674-9686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant