Provider Demographics
NPI:1629824032
Name:VANDERBOEGH, LACI JO (MSN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:LACI
Middle Name:JO
Last Name:VANDERBOEGH
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 GREENBRIAR RD NW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-2146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 TARBORO ST W STE 100
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3481
Practice Address - Country:US
Practice Address - Phone:252-399-5314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5019962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily