Provider Demographics
NPI:1033853213
Name:IANUA HEALTH, LLC
Entity Type:Organization
Organization Name:IANUA HEALTH, LLC
Other - Org Name:KETAMINDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDULLA
Authorized Official - Suffix:JR
Authorized Official - Credentials:FNP
Authorized Official - Phone:610-998-3902
Mailing Address - Street 1:2207 CONCORD PIKE # 197
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-2908
Mailing Address - Country:US
Mailing Address - Phone:610-998-3902
Mailing Address - Fax:610-702-8056
Practice Address - Street 1:14 ROGERS RD STE 211
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-3612
Practice Address - Country:US
Practice Address - Phone:410-280-7683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-25
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty