Healthcare Provider Details

I. General information

NPI: 1760318117
Provider Name (Legal Business Name): KEONNA FORD
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8823 N 79TH ST
OMAHA NE
68122-4095
US

IV. Provider business mailing address

11550 I ST STE 100
OMAHA NE
68137-1222
US

V. Phone/Fax

Practice location:
  • Phone: 402-498-4700
  • Fax:
Mailing address:
  • Phone: 402-498-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: