Healthcare Provider Details

I. General information

NPI: 1124129358
Provider Name (Legal Business Name): STACEY JEANNE PAPPAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 CAROLINE ST UNIT A
BUNNELL FL
32110-8904
US

IV. Provider business mailing address

42 CAROLINE ST UNIT A
BUNNELL FL
32110-8904
US

V. Phone/Fax

Practice location:
  • Phone: 386-425-4470
  • Fax: 386-425-4471
Mailing address:
  • Phone: 386-425-4470
  • Fax: 386-425-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME93828
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD14404
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD14404
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME93828
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: