Provider Demographics
NPI:1144500398
Name:ANTONYAN, HOLLY GRUWELL (NP)
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:GRUWELL
Last Name:ANTONYAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:M
Other - Last Name:GRUWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28625 S WESTERN AVE # 55
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-0810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24520 HAWTHORNE BLVD STE 240
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6849
Practice Address - Country:US
Practice Address - Phone:310-300-6206
Practice Address - Fax:310-919-3703
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21075363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner