Provider Demographics
NPI:1992459028
Name:STARK, BROOKE ANNE (FNP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANNE
Last Name:STARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-2407
Mailing Address - Country:US
Mailing Address - Phone:518-260-8020
Mailing Address - Fax:
Practice Address - Street 1:5 CLAY ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1905
Practice Address - Country:US
Practice Address - Phone:518-483-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine