Provider Demographics
NPI:1144397506
Name:MYLOTT-FASANO, MARY ELIZABETH (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:MYLOTT-FASANO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:MYLOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:85 SCHRADE RD
Mailing Address - Street 2:
Mailing Address - City:BRIARCLIFF MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10510-1410
Mailing Address - Country:US
Mailing Address - Phone:914-610-5225
Mailing Address - Fax:
Practice Address - Street 1:NORTH CENTRAL BRONX HOSPITAL
Practice Address - Street 2:3424 KOSSUTH AVE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-918-4012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330975363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics