Healthcare Provider Details

I. General information

NPI: 1104309236
Provider Name (Legal Business Name): KAYLEY ANN OLIVERI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 DEL PRADO BLVD S
CAPE CORAL FL
33990-2668
US

IV. Provider business mailing address

4661 LONG LAKE DR
FORT MYERS FL
33905-5809
US

V. Phone/Fax

Practice location:
  • Phone: 239-772-6513
  • Fax:
Mailing address:
  • Phone: 239-910-2490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111591
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: