Healthcare Provider Details

I. General information

NPI: 1053106344
Provider Name (Legal Business Name): KAITLIN KAYLA PABUSTAN VILORIA-ELLORIN MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-5972
  • Fax:
Mailing address:
  • Phone: 210-292-5972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number6352000935
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: