Provider Demographics
NPI:1184175697
Name:ODEWALE, YEKEEN
Entity type:Individual
Prefix:
First Name:YEKEEN
Middle Name:
Last Name:ODEWALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 OLD FREDERICK RD STE 7
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-2126
Mailing Address - Country:US
Mailing Address - Phone:410-762-8945
Mailing Address - Fax:
Practice Address - Street 1:4515 HIDDEN STREAM CT
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4837
Practice Address - Country:US
Practice Address - Phone:410-300-6461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR212715163WP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD117396100Medicaid