Provider Demographics
NPI:1861498917
Name:SULLINS, CHRISTA H (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:H
Last Name:SULLINS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-3621
Mailing Address - Country:US
Mailing Address - Phone:423-745-4910
Mailing Address - Fax:423-745-2230
Practice Address - Street 1:517 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3621
Practice Address - Country:US
Practice Address - Phone:423-745-4910
Practice Address - Fax:423-745-2230
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000001689152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3066158Medicaid
TN3940594Medicare ID - Type Unspecified
TN3066158Medicaid