Provider Demographics
NPI:1134956808
Name:MOLLICONE, CARLY LAUREN (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:LAUREN
Last Name:MOLLICONE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 N ST STE N
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5712
Mailing Address - Country:US
Mailing Address - Phone:951-450-8992
Mailing Address - Fax:951-257-9529
Practice Address - Street 1:41197 GOLDEN GATE CIR STE 201
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-6999
Practice Address - Country:US
Practice Address - Phone:951-450-8992
Practice Address - Fax:951-257-9529
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61616500363LP0808X
CA95032179363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health