Provider Demographics
NPI:1841241429
Name:TENNISWOOD, CHRISTINE MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MICHELLE
Last Name:TENNISWOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 WOODBINE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8790
Mailing Address - Country:US
Mailing Address - Phone:850-994-6575
Mailing Address - Fax:850-994-5643
Practice Address - Street 1:4225 WOODBINE ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571
Practice Address - Country:US
Practice Address - Phone:850-994-6575
Practice Address - Fax:850-994-5643
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0427283207Q00000X
FLME111479207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100335530BMedicaid
G85727Medicare UPIN
KS0337235DMedicare ID - Type Unspecified