Healthcare Provider Details

I. General information

NPI: 1114578853
Provider Name (Legal Business Name): ERICA LEAH STOLLER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 J CLYDE MORRIS BLVD
NEWPORT NEWS VA
23601-1929
US

IV. Provider business mailing address

500 J CLYDE MORRIS BLVD
NEWPORT NEWS VA
23601-1929
US

V. Phone/Fax

Practice location:
  • Phone: 757-594-3945
  • Fax:
Mailing address:
  • Phone: 757-594-3945
  • Fax: 757-594-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9112532
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number9112532
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: