Healthcare Provider Details

I. General information

NPI: 1134847288
Provider Name (Legal Business Name): KEANAH FOREMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/16/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10520 SUMMER AZURE DR
RIVERVIEW FL
33578-5828
US

IV. Provider business mailing address

10520 SUMMER AZURE DR
RIVERVIEW FL
33578-5828
US

V. Phone/Fax

Practice location:
  • Phone: 813-334-4718
  • Fax:
Mailing address:
  • Phone: 813-334-4718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: