Provider Demographics
NPI:1922095637
Name:SONG, SOONOK (RN)
Entity Type:Individual
Prefix:
First Name:SOONOK
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29466 PINTAIL DR
Mailing Address - Street 2:SUITE 9
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-9323
Mailing Address - Country:US
Mailing Address - Phone:410-770-5140
Mailing Address - Fax:410-770-5141
Practice Address - Street 1:2301 LIBERTY HEIGHTS AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-8019
Practice Address - Country:US
Practice Address - Phone:410-462-3532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR057717163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD836LMedicare ID - Type Unspecified
S57736Medicare UPIN