Basic Information
| Provider Information | |||||||||
| NPI: | 1215220827 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VON GRUENIGEN | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | D'LANA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708641472 | ||||||||
| FaxNumber: | 2708641693 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 STEVE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELL SPRINGS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426424622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708663161 | ||||||||
| FaxNumber: | 2708663163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2011 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 03704 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100248610 | 05 | KY | MEDICAID |