Provider Demographics
NPI:1154002475
Name:BROCKER, STEFANIE RAE (RD)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:RAE
Last Name:BROCKER
Suffix:
Gender:
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4124 FALLS RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-1641
Mailing Address - Country:US
Mailing Address - Phone:540-761-4269
Mailing Address - Fax:
Practice Address - Street 1:800 LINDEN AVE FL 8
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4622
Practice Address - Country:US
Practice Address - Phone:443-682-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86043008133V00000X
MDDX4893133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered