Provider Demographics
NPI:1316737729
Name:CARLYLE, MOLLI
Entity type:Individual
Prefix:
First Name:MOLLI
Middle Name:
Last Name:CARLYLE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1954
Mailing Address - Country:US
Mailing Address - Phone:217-820-5720
Mailing Address - Fax:
Practice Address - Street 1:401 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-820-5720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker