Provider Demographics
NPI:1700552791
Name:VILLEGAS, KYLIE LAUREN
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:LAUREN
Last Name:VILLEGAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3698 CHAMBERS PASS BLDG 3611
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7766
Mailing Address - Country:US
Mailing Address - Phone:210-916-5658
Mailing Address - Fax:210-271-0830
Practice Address - Street 1:9898 COLONNADE BLVD APT 6207
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2271
Practice Address - Country:US
Practice Address - Phone:361-550-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA15623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program