Lacey Jean Wildeboer, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

0010-07379 Issued in NC

Practice address

400 N Englewood Dr
Kenly, NC 27542-9290

Phone

(919) 284-4149

Fax

(919) 284-6008

NPI assigned

Jul 26, 2017

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2017

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Unc Physicians Network LLCGroup PAC ID 5496940546, 985 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Rex Hospital Hospital, Raleigh, NC, CCN 340114
• Johnston Health Hospital, Smithfield, NC, CCN 340090

Medicare enrollment (NPD)

Not enrolled

HHS exclusion list flag

Flagged The directory lists this NPI on an HHS exclusion list. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: lwildeboer1133409@direct.unc.nchie.net

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Unc Physicians Network LLC

  • Family Medicine Physician
  • Pittsboro, NC
  • NPI 1750704367
  Medicare reassignment Care Compare group NPD
• Minuteclinic Diagnostic of North Carolina PC

  • Family Nurse Practitioner
  • Raleigh, NC
  • NPI 1699748608
  Medicare reassignment
• Unc Physicians Network LLC

  • General Practice Physician
  • Morrisville, NC
  • NPI 1558786830
  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Johnston Health Services Corporation

  • General Acute Care Hospital
  • Smithfield, NC
  • NPI 1619911104
  Care Compare affiliation
• Rex Hospital Inc.

  • General Acute Care Hospital
  • Raleigh, NC
  • NPI 1497797088
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1501027200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1759449600000",
    "number": "1477077089",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5221 PARAMOUNT PKWY STE 220",
            "city": "MORRISVILLE",
            "state": "NC",
            "postal_code": "275605490",
            "telephone_number": "984-215-4111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 N ENGLEWOOD DR",
            "city": "KENLY",
            "state": "NC",
            "postal_code": "275429290",
            "telephone_number": "919-284-4149",
            "fax_number": "919-284-6008"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "7201 US Highway 64 E",
            "address_purpose": "LOCATION",
            "city": "Knightdale",
            "state": "NC",
            "postal_code": "275459268",
            "country_code": "US",
            "telephone_number": "919-266-7600",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WILDEBOER",
        "first_name": "LACEY",
        "middle_name": "JEAN",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-07-26",
        "last_updated": "2025-10-03",
        "certification_date": "2025-10-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-07379",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "lwildeboer1133409@direct.UNC.nchie.net",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CDA/CCD/TXT",
            "address_1": "400 N Englewood Dr",
            "city": "kenly",
            "state": "NC",
            "country_code": "US",
            "postal_code": "275429290",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Renal Treatment Centers Mid Atlantic Inc
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• David Douglas Whitfield
• Brock Elliot Wiley, PHARM.D
• Jessica Patreece Wilson, NP
• Hal B Woodall, MD
• Taylor Suzanne Woodard

• Physician Assistant in Kenly, NC
• Providers in Kenly, NC by specialty
• Physician Assistant in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 3, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.