Provider Demographics
NPI:1568238392
Name:PETTIS, BROOKE (RDN)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:PETTIS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 N PARK AVE # 1
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216-2817
Mailing Address - Country:US
Mailing Address - Phone:716-906-7570
Mailing Address - Fax:
Practice Address - Street 1:7 ONONDAGA ST
Practice Address - Street 2:
Practice Address - City:SKANEATELES
Practice Address - State:NY
Practice Address - Zip Code:13152-1313
Practice Address - Country:US
Practice Address - Phone:315-710-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011110133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered