Healthcare Provider Details

I. General information

NPI: 1437094620
Provider Name (Legal Business Name): BROOKE WATERS
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 THAMES ST STE 101
BALTIMORE MD
21231-3661
US

IV. Provider business mailing address

1440 CROW HAVEN LN
HUNTINGTOWN MD
20639-9790
US

V. Phone/Fax

Practice location:
  • Phone: 443-885-9644
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR228466
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: