Provider Demographics
NPI:1982365979
Name:BELLAMY, SHAVONE
Entity Type:Individual
Prefix:
First Name:SHAVONE
Middle Name:
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 1:2164 US HIGHWAY 84
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-1160
Mailing Address - Country:US
Mailing Address - Phone:254-458-4138
Mailing Address - Fax:
Practice Address - Street 1:108 KINGSLEY AVE STE 210
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5685
Practice Address - Country:US
Practice Address - Phone:912-722-3281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744P3200X
GA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management