Provider Demographics
NPI:1427546936
Name:OLIVETO, DANIELLE ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:ROSE
Last Name:OLIVETO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2373
Mailing Address - Country:US
Mailing Address - Phone:704-323-2505
Mailing Address - Fax:
Practice Address - Street 1:197 PIEDMONT BLVD STE 111
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1825
Practice Address - Country:US
Practice Address - Phone:803-328-6306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0397730048OtherNSC#