Provider Demographics
NPI:1669627899
Name:GRUNEBACH, HOLLY L (PA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:L
Last Name:GRUNEBACH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-2704
Mailing Address - Fax:
Practice Address - Street 1:4320 SEMINARY ROAD
Practice Address - Street 2:ALEXANDRIA HOSPITAL
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-504-3066
Practice Address - Fax:703-504-3866
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002874207P00000X
MDC04034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine