Provider Demographics
NPI:1659998425
Name:BELLOMY, RYAN MATTHEW (AGACNP, FNP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:BELLOMY
Suffix:
Gender:M
Credentials:AGACNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 W MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-4150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1114 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4150
Practice Address - Country:US
Practice Address - Phone:423-745-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-28
Last Update Date:2020-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27489363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner