Provider Demographics
NPI:1215220827
Name:VON GRUENIGEN, HOLLY D'LANA (DO)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:D'LANA
Last Name:VON GRUENIGEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-864-1472
Mailing Address - Fax:270-864-1693
Practice Address - Street 1:404 STEVE DR
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-4622
Practice Address - Country:US
Practice Address - Phone:270-866-3161
Practice Address - Fax:270-866-3163
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03704208000000X
KYR2664208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100248610Medicaid