Provider Demographics
NPI:1578855250
Name:SWEENEY, ISHARA (LAC)
Entity Type:Individual
Prefix:
First Name:ISHARA
Middle Name:
Last Name:SWEENEY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ISHARA
Other - Middle Name:
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:PO BOX 9145
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-1145
Mailing Address - Country:US
Mailing Address - Phone:707-843-3957
Mailing Address - Fax:
Practice Address - Street 1:1819 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3202
Practice Address - Country:US
Practice Address - Phone:707-843-3957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14291171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist