Provider Demographics
NPI:1932762556
Name:GRUENEWALD, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:GRUENEWALD
Suffix:
Gender:F
Credentials:
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 1337
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92393-1337
Mailing Address - Country:US
Mailing Address - Phone:760-403-0049
Mailing Address - Fax:
Practice Address - Street 1:18788 NATIONAL TRAILS HWY
Practice Address - Street 2:
Practice Address - City:ORO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:92368-9577
Practice Address - Country:US
Practice Address - Phone:760-403-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL7161247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other