Provider Demographics
NPI:1104202720
Name:HALLER, ASHLEY (NP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:HALLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GRESHAM DR STE 303
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1901
Mailing Address - Country:US
Mailing Address - Phone:757-627-6416
Mailing Address - Fax:757-627-3709
Practice Address - Street 1:400 GRESHAM DR STE 303
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1901
Practice Address - Country:US
Practice Address - Phone:757-627-6416
Practice Address - Fax:757-627-3709
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172820363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner