Provider Demographics
NPI:1366477960
Name:WATERS, BRENDA LORRAINE (MD, BS)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:LORRAINE
Last Name:WATERS
Suffix:
Gender:F
Credentials:MD, BS
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 BLACKBERRY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05462-9640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2797
Practice Address - Fax:802-847-9644
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0006733207ZP0101X, 207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Not Answered207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01166976Medicaid
VT0009551Medicaid
VTWAVT9551Medicare ID - Type Unspecified
VT0009551Medicaid