Provider Demographics
NPI:1790719748
Name:JERIDEAU, SAMUEL LAMONT (RN)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LAMONT
Last Name:JERIDEAU
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1459 ACTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-3338
Mailing Address - Country:US
Mailing Address - Phone:972-780-0118
Mailing Address - Fax:972-780-0491
Practice Address - Street 1:1459 ACTON AVE
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-3338
Practice Address - Country:US
Practice Address - Phone:972-780-0118
Practice Address - Fax:972-780-0491
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX651668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily