Provider Demographics
NPI:1982579900
Name:SULLIVAN, CORINNE MARIE
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-2207
Mailing Address - Country:US
Mailing Address - Phone:907-306-2003
Mailing Address - Fax:
Practice Address - Street 1:529 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-2207
Practice Address - Country:US
Practice Address - Phone:907-306-2003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-08
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK147794156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician