Provider Demographics
NPI:1447603246
Name:DUDENBOSTEL, MINDY M (CNP)
Entity Type:Individual
Prefix:MRS
First Name:MINDY
Middle Name:M
Last Name:DUDENBOSTEL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:MINDY
Other - Middle Name:M
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1239 EAST MAIN ST
Mailing Address - Street 2:PO BOX 3988
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:2808 OUTER DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:844-988-7900
Practice Address - Fax:618-993-3908
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily