Healthcare Provider Details

I. General information

NPI: 1154002475
Provider Name (Legal Business Name): STEFANIE RAE BROCKER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 LINDEN AVE FL 8
BALTIMORE MD
21201-4622
US

IV. Provider business mailing address

4124 FALLS RD
BALTIMORE MD
21211-1641
US

V. Phone/Fax

Practice location:
  • Phone: 443-682-6800
  • Fax:
Mailing address:
  • Phone: 540-761-4269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX4893
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86043008
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: