Healthcare Provider Details

I. General information

NPI: 1376408567
Provider Name (Legal Business Name): MS. GRACE VANDER MOLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3011
US

IV. Provider business mailing address

224 WELLINGTON RD
SYRACUSE NY
13214-2226
US

V. Phone/Fax

Practice location:
  • Phone: 315-877-8764
  • Fax:
Mailing address:
  • Phone: 315-877-8764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number867833
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: