Provider Demographics
NPI:1093132482
Name:KRUBALLY, JAYE
Entity Type:Individual
Prefix:
First Name:JAYE
Middle Name:
Last Name:KRUBALLY
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 1:4125 BROADWAY BLVD STE 120C
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-2500
Mailing Address - Country:US
Mailing Address - Phone:972-303-0861
Mailing Address - Fax:972-303-0928
Practice Address - Street 1:4125 BROADWAY BLVD # BLVEC120
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-2500
Practice Address - Country:US
Practice Address - Phone:972-303-0861
Practice Address - Fax:972-303-0928
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX670203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8122NJOtherBLUECROSS