Provider Demographics
NPI:1649290941
Name:WICKLUND, CORINNE BEIERSDORF (OD)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:BEIERSDORF
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CORINNE
Other - Middle Name:
Other - Last Name:BEIERSDORF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-0600
Mailing Address - Country:US
Mailing Address - Phone:920-893-3937
Mailing Address - Fax:920-892-6668
Practice Address - Street 1:100 CARR RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-9500
Practice Address - Country:US
Practice Address - Phone:920-892-3937
Practice Address - Fax:920-892-6668
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3046-035152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3046-035OtherSTATE LICENSE NUMBER