Provider Demographics
NPI:1801198460
Name:BELLAMY, STEPHANIE L
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:L
Last Name:BELLAMY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3056 W. 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-2539
Mailing Address - Country:US
Mailing Address - Phone:904-388-7086
Mailing Address - Fax:904-388-7086
Practice Address - Street 1:3056 W. 1ST STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-2539
Practice Address - Country:US
Practice Address - Phone:904-388-7086
Practice Address - Fax:904-388-7086
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10793310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142571400Medicaid
FL142571496OtherMED-WAIVER
FL310400000XMedicaid