Provider Demographics
NPI:1154673499
Name:SWEENEY, NEVADA RAE (OD)
Entity Type:Individual
Prefix:
First Name:NEVADA
Middle Name:RAE
Last Name:SWEENEY
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 1:1205 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843
Mailing Address - Country:US
Mailing Address - Phone:208-882-3434
Mailing Address - Fax:
Practice Address - Street 1:1205 E 6TH ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-882-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP - 100388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist