Basic Information
| Provider Information | |||||||||
| NPI: | 1114128725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ-BONILLA | ||||||||
| FirstName: | KEILAH | ||||||||
| MiddleName: | ISABEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4623 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378024623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1811 LITTLE CREEK LN | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379226002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656906727 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME96511 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 45347 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QH0002X | 45347 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207Q00000X | 45347 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1521768 | 05 | TN | MEDICAID |