Provider Demographics
NPI:1407480817
Name:DIFFANG, SUNNY BESONG (CRNP)
Entity Type:Individual
Prefix:MR
First Name:SUNNY
Middle Name:BESONG
Last Name:DIFFANG
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3523 CORN STREAM RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2442
Mailing Address - Country:US
Mailing Address - Phone:410-528-3866
Mailing Address - Fax:
Practice Address - Street 1:3523 CORN STREAM RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-2442
Practice Address - Country:US
Practice Address - Phone:410-528-3866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202090363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health