Provider Demographics
NPI:1104284462
Name:JANKE, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:JANKE
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 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-0544
Mailing Address - Country:US
Mailing Address - Phone:409-747-7369
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0544
Practice Address - Country:US
Practice Address - Phone:409-747-7369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX805797363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner