Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 45347 | TN |
N | 207Q00000X | Family Doctor | ME96511 | FL |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 45347 | TN |
N | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | 45347 | TN |
NPI | 1114128725 |
---|---|
Provider Name | Keilah Isabel Gonzalez-Bonilla |
First Address | Maryville, TN 37802-4623 |
Second Address | Knoxville, TN 37922-6002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/05/2007 |
Last Update Date | 19/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1521768 | (05) | TN |