Healthcare Provider Details

I. General information

NPI: 1386211415
Provider Name (Legal Business Name): STACEY CHALYN REGIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date: 03/16/2023
Reactivation Date: 03/21/2023

III. Provider practice location address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

IV. Provider business mailing address

1611 NW 12 AVENUE
MIAMI FL
33136
US

V. Phone/Fax

Practice location:
  • Phone: 904-953-2000
  • Fax:
Mailing address:
  • Phone: 305-585-5215
  • Fax: 305-585-8137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME166909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: