Basic Information
| Provider Information | |||||||||
| NPI: | 1427546936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLIVETO | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 PARK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282092373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 197 PIEDMONT BLVD STE 111 | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033286306 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2018 | ||||||||
| LastUpdateDate: | 09/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3295 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0397730048 | 01 | SC | NSC# | OTHER |