Provider Demographics
NPI:1063043271
Name:JUBALA, KATIE LIANNE (FNP-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LIANNE
Last Name:JUBALA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 SPANISH MOSS CIR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6417
Mailing Address - Country:US
Mailing Address - Phone:909-645-5684
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-6153
Practice Address - Fax:318-675-8081
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144824207QA0505X
LA21224363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine