Provider Demographics
NPI:1598964629
Name:DE GRAVELLE, OLIVER LOUIS III (APRN)
Entity Type:Individual
Prefix:MR
First Name:OLIVER
Middle Name:LOUIS
Last Name:DE GRAVELLE
Suffix:III
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1231
Mailing Address - Country:US
Mailing Address - Phone:919-350-8000
Mailing Address - Fax:
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:919-350-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02915363L00000X
LAAP02915363LN0000X
NC5015451363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner