Provider Demographics
NPI:1851047690
Name:SONJONG, DERICK (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:SONJONG
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4507 LYONS RUN CIR APT T3
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-6979
Mailing Address - Country:US
Mailing Address - Phone:571-277-0779
Mailing Address - Fax:
Practice Address - Street 1:4507 LYONS RUN CIR APT T3
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-6979
Practice Address - Country:US
Practice Address - Phone:571-277-0779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR204750363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health