MEDICARE: SAMANTHA DESRUISSEAUX RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1780575050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA DESRUISSEAUX RN

Provider Business Mailing Address
First Line	:	100 WASHINGTON AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55401-2110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9130 E ELLIOT RD
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85212-9675
Country	:	US
Telephone Number	:	480-410-4100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2025
Last Update Date	:	07/18/2025

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