Healthcare Provider Details

I. General information

NPI: 1295299212
Provider Name (Legal Business Name): GILLIAN BELLONI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 WELAKA WAY
ST AUGUSTINE FL
32092-2459
US

IV. Provider business mailing address

1016 WELAKA WAY
ST AUGUSTINE FL
32092-2459
US

V. Phone/Fax

Practice location:
  • Phone: 904-495-4583
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: