Healthcare Provider Details

I. General information

NPI: 1891113205
Provider Name (Legal Business Name): STACEY MICHELLE NEDRUD MD, DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7711 BAYMEADOWS RD E STE 7
JACKSONVILLE FL
32256-9110
US

IV. Provider business mailing address

7711 BAYMEADOWS RD E STE 7
JACKSONVILLE FL
32256-9110
US

V. Phone/Fax

Practice location:
  • Phone: 321-591-1840
  • Fax:
Mailing address:
  • Phone: 321-591-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberME149400
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: