Healthcare Provider Details

I. General information

NPI: 1689295941
Provider Name (Legal Business Name): KEYONA CHANELL GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 2ND AVE NW
MANDAN ND
58554-3124
US

IV. Provider business mailing address

135 NEW JERSEY ST
BISMARCK ND
58504-6741
US

V. Phone/Fax

Practice location:
  • Phone: 701-667-3383
  • Fax: 701-667-3203
Mailing address:
  • Phone: 701-667-3378
  • Fax: 701-667-3384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number5296
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: