MEDICARE: DR. SAMUEL LAMONT JERIDEAU FNP

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	363LF0000X	Family Nurse Practitioner	895490	NV

General Provider Information

NPI Number	:	1790719748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL LAMONT JERIDEAU FNP

Provider Business Mailing Address
First Line	:	3172 N RAINBOW BLVD # 1122
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-4534
Country	:	US
Telephone Number	:	214-516-4681
Fax Number	:	702-395-0018

Provider Business Practice Location Address
First Line	:	3249 W CRAIG RD STE 140
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-0789
Country	:	US
Telephone Number	:	702-329-1732
Fax Number	:	702-410-5553

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	06/15/2026

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