Provider Demographics
NPI:1720963572
Name:TENNIS, BROOKE M
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:M
Last Name:TENNIS
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 1:790 STONE ARABIA RD
Mailing Address - Street 2:
Mailing Address - City:FORT PLAIN
Mailing Address - State:NY
Mailing Address - Zip Code:13339-1925
Mailing Address - Country:US
Mailing Address - Phone:518-774-1817
Mailing Address - Fax:
Practice Address - Street 1:5010 STATE HIGHWAY 30 STE 204
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7532
Practice Address - Country:US
Practice Address - Phone:518-842-8185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF357184-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily