Provider Demographics
NPI:1164473765
Name:SWEENEY, NICOLE (PA-C, RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SWEENEY
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 WRONDEL WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-3310
Mailing Address - Country:US
Mailing Address - Phone:775-750-5046
Mailing Address - Fax:
Practice Address - Street 1:1155 MILL ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1576
Practice Address - Country:US
Practice Address - Phone:775-982-4330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV40306-DI-0133V00000X
NVPA949363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100509175Medicaid