Provider Demographics
NPI:1699201277
Name:CHURLONIS, MOLLY ANNE
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANNE
Last Name:CHURLONIS
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 1:147 W CANADA APT B
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4664
Mailing Address - Country:US
Mailing Address - Phone:949-306-1784
Mailing Address - Fax:
Practice Address - Street 1:29100 PORTOLA PKWY STE G
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8712
Practice Address - Country:US
Practice Address - Phone:844-254-6382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54884363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical