Healthcare Provider Details

I. General information

NPI: 1184175697
Provider Name (Legal Business Name): YEKEEN ODEWALE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 HIDDEN STREAM CT
OWINGS MILLS MD
21117-4837
US

IV. Provider business mailing address

5411 OLD FREDERICK RD STE 7
BALTIMORE MD
21229-2126
US

V. Phone/Fax

Practice location:
  • Phone: 410-300-6461
  • Fax:
Mailing address:
  • Phone: 410-762-8945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR212715
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR212715
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: