Healthcare Provider Details

I. General information

NPI: 1659998425
Provider Name (Legal Business Name): RYAN MATTHEW BELLOMY AGACNP, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2020
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WALMART DR
SODDY DAISY TN
37379-5022
US

IV. Provider business mailing address

210 WALMART DR
SODDY DAISY TN
37379-5022
US

V. Phone/Fax

Practice location:
  • Phone: 423-332-6155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number27489
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number27489
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: