Provider Demographics
NPI:1962218503
Name:FONSECA, KEILA
Entity type:Individual
Prefix:
First Name:KEILA
Middle Name:
Last Name:FONSECA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 PARK FOREST WAY
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-4976
Mailing Address - Country:US
Mailing Address - Phone:561-920-9500
Mailing Address - Fax:
Practice Address - Street 1:1117 ROYAL PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-1641
Practice Address - Country:US
Practice Address - Phone:561-920-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11036579363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily