Provider Demographics
NPI:1417901109
Name:DUNTLEY, JODIE (CNS, MS)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:DUNTLEY
Suffix:
Gender:F
Credentials:CNS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVE # S1
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-6800
Practice Address - Fax:612-904-4322
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN348363-05364S00000X
MNR 115323-1364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0006633800Medicaid
MN0006633800Medicaid
S78011Medicare UPIN