Healthcare Provider Details

I. General information

NPI: 1982365979
Provider Name (Legal Business Name): SHAVONE BELLAMY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 KINGSLEY AVE STE 210
ORANGE PARK FL
32073-5685
US

IV. Provider business mailing address

2164 US HIGHWAY 84
BLACKSHEAR GA
31516-1160
US

V. Phone/Fax

Practice location:
  • Phone: 912-722-3281
  • Fax:
Mailing address:
  • Phone: 254-458-4138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: