Provider Demographics
NPI:1639433691
Name:FACELO, MYLANIE C (DO)
Entity Type:Individual
Prefix:DR
First Name:MYLANIE
Middle Name:C
Last Name:FACELO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 E SPEEDWAY BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-3928
Mailing Address - Country:US
Mailing Address - Phone:520-833-5171
Mailing Address - Fax:
Practice Address - Street 1:5555 E RIVER RD # 219
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-1949
Practice Address - Country:US
Practice Address - Phone:520-314-4275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR73583207Q00000X
VA0116028424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR73583OtherTRAINING PERMIT