Provider Demographics
NPI:1184387938
Name:VANDERBOOM, MOLLY ANN (MED, ATC, LAT, OPE)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:VANDERBOOM
Suffix:
Gender:F
Credentials:MED, ATC, LAT, OPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 EAGLE VISTA LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-4413
Mailing Address - Country:US
Mailing Address - Phone:319-360-8286
Mailing Address - Fax:
Practice Address - Street 1:5155 55TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-3855
Practice Address - Country:US
Practice Address - Phone:507-292-7174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer