Healthcare Provider Details

I. General information

NPI: 1285019695
Provider Name (Legal Business Name): KENNETH VICKROY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W THOMAS RD STE 114
PHOENIX AZ
85013-4420
US

IV. Provider business mailing address

222 W THOMAS RD STE 114
PHOENIX AZ
85013-4420
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-4578
  • Fax: 602-424-5445
Mailing address:
  • Phone: 602-406-4578
  • Fax: 602-424-5445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8000
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: