Healthcare Provider Details

I. General information

NPI: 1447603246
Provider Name (Legal Business Name): MINDY M DUDENBOSTEL CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MINDY M GRACE

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 STATE ST
CHESTER IL
62233-1116
US

IV. Provider business mailing address

1900 STATE ST
CHESTER IL
62233-1116
US

V. Phone/Fax

Practice location:
  • Phone: 618-826-2388
  • Fax: 618-826-5139
Mailing address:
  • Phone: 618-826-4581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014495
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: