Provider Demographics
NPI:1356926455
Name:ADEKUNLE, MODUPE
Entity type:Individual
Prefix:
First Name:MODUPE
Middle Name:
Last Name:ADEKUNLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1657 WHITEHEAD CT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-4037
Mailing Address - Country:US
Mailing Address - Phone:443-200-3653
Mailing Address - Fax:301-736-1275
Practice Address - Street 1:1657 WHITEHEAD CT
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-4037
Practice Address - Country:US
Practice Address - Phone:443-200-3653
Practice Address - Fax:667-220-5942
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024181084363LP0808X
MDR213801363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health