MEDICARE: MR. ANTONIO PEDULLA JR. CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	SP024827	PA
2	163W00000X	Registered Nurse	RN674446	PA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	SP027026	PA

General Provider Information

NPI Number	:	1518622455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANTONIO PEDULLA JR. CRNP

Provider Business Mailing Address
First Line	:	2207 CONCORD PIKE # 197
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19803-2908
Country	:	US
Telephone Number	:	610-998-3902
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 ROGERS RD STE 211
Second Line	:
City	:	NORTH EAST
State	:	MD
Zip	:	21901-3612
Country	:	US
Telephone Number	:	410-280-7683
Fax Number	:	610-702-8056

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2021
Last Update Date	:	02/13/2025

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