| Lifesource Prime Inc | |
|
3205 Randall Pkwy Ste 105 Wilmington NC 28403-2565 | |
| (910) 742-9243 | |
| (888) 746-1787 |
| Full Name | Lifesource Prime Inc |
|---|---|
| Speciality | Family Medicine |
| Location | 3205 Randall Pkwy Ste 105, Wilmington, North Carolina |
| Authorized Official Name and Position | Peggy Baddour (CEO) |
| Authorized Official Contact | 9107429243 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lifesource Prime Inc Po Box 740343 Atlanta GA 30374-0343 Ph: (910) 338-2882 | Lifesource Prime Inc 3205 Randall Pkwy Ste 105 Wilmington NC 28403-2565 Ph: (910) 742-9243 |
| NPI Number | 1598533275 |
|---|---|
| Provider Enumeration Date | 12/13/2023 |
| Last Update Date | 10/28/2025 |
| Certification Date | 10/28/2025 |
| Medicare PECOS PAC ID | 7810336385 |
|---|---|
| Medicare Enrollment ID | O20240416003922 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1598533275 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | () | Primary |
| Provider Name | Loyce L Brown |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1962477984 PECOS PAC ID: 6002826047 Enrollment ID: I20060504000439 |
| Provider Name | Sachin S Mody |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1730106444 PECOS PAC ID: 7214932482 Enrollment ID: I20070409000492 |
| Provider Name | Patrick V Mcconnell |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1215904818 PECOS PAC ID: 5092629337 Enrollment ID: I20070807000849 |
| Provider Name | Marilyn Christine Madden |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1902923055 PECOS PAC ID: 8325134562 Enrollment ID: I20071018000516 |
| Provider Name | Cynthia K Honeycutt |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1528215407 PECOS PAC ID: 3375602980 Enrollment ID: I20081111000281 |
| Provider Name | Janet L Poindexter |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1578564803 PECOS PAC ID: 7618967282 Enrollment ID: I20090117000112 |
| Provider Name | Jennifer Lynn Jenkins |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1437393774 PECOS PAC ID: 2668516584 Enrollment ID: I20100216000528 |
| Provider Name | Laura Ann Ivey |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1578848735 PECOS PAC ID: 1355516352 Enrollment ID: I20111201000781 |
| Provider Name | Megan M Grady |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1447595608 PECOS PAC ID: 4789837972 Enrollment ID: I20130122000365 |
| Provider Name | Linda Cappiello |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1174633457 PECOS PAC ID: 6901815836 Enrollment ID: I20140225002062 |
| Provider Name | Pacharo Nyirongo Ndupu |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194167080 PECOS PAC ID: 7618107335 Enrollment ID: I20150106001574 |
| Provider Name | Crystal Prince Ostheim |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1821490434 PECOS PAC ID: 5890019699 Enrollment ID: I20150127002361 |
| Provider Name | Danyel Sutton Vines |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1093187403 PECOS PAC ID: 7214230242 Enrollment ID: I20160125001685 |
| Provider Name | Heather Mcfarland |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1508258583 PECOS PAC ID: 2668773243 Enrollment ID: I20161011000929 |
| Provider Name | Eurica D Manning |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1427421189 PECOS PAC ID: 2668755828 Enrollment ID: I20170214000186 |
| Provider Name | July Romely Damour |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1851470215 PECOS PAC ID: 2567656457 Enrollment ID: I20170626000484 |
| Provider Name | Kristina L Polley |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1700274313 PECOS PAC ID: 4688991177 Enrollment ID: I20170831000025 |
| Provider Name | Megan Katherine Blankenship |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1366969834 PECOS PAC ID: 4880960970 Enrollment ID: I20171017002159 |
| Provider Name | Megan Lynnette Giere |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1790077071 PECOS PAC ID: 9830368265 Enrollment ID: I20180926004226 |
| Provider Name | Jennifer Lauren Nelson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1740762947 PECOS PAC ID: 0547513574 Enrollment ID: I20181022001455 |
| Provider Name | Maggie Elizabeth Mclaughlin |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1356821086 PECOS PAC ID: 2769735174 Enrollment ID: I20181101002463 |
| Provider Name | Edna Obehi Idehen |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1780170571 PECOS PAC ID: 7416200779 Enrollment ID: I20181102001627 |
| Provider Name | Felicia Harrell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1497130306 PECOS PAC ID: 6002125101 Enrollment ID: I20181228000547 |
| Provider Name | Carly Armato Saulters |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1275015380 PECOS PAC ID: 1557607660 Enrollment ID: I20190110002145 |
| Provider Name | Quintina B Petty |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1851862734 PECOS PAC ID: 1951649896 Enrollment ID: I20190219000947 |
| Provider Name | Shannon Blake |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1578509238 PECOS PAC ID: 6406943448 Enrollment ID: I20190624003539 |
| Provider Name | Megan D Long |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1952950859 PECOS PAC ID: 0941633382 Enrollment ID: I20191126000062 |
| Provider Name | William B Holder |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1316168602 PECOS PAC ID: 7911332838 Enrollment ID: I20200122002148 |
| Provider Name | Glenda Pulliam |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1952871055 PECOS PAC ID: 4082882139 Enrollment ID: I20200514001493 |
| Provider Name | Elena Antonia Morgan |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1649653197 PECOS PAC ID: 5193052090 Enrollment ID: I20201103001038 |
| Provider Name | Roberto Antonio Marsico |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1225404635 PECOS PAC ID: 7012282395 Enrollment ID: I20201118002154 |
| Provider Name | Brandy Hunter Clark |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1902405095 PECOS PAC ID: 7416369764 Enrollment ID: I20201210002175 |
| Provider Name | Ishan Bhansaly |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1972824357 PECOS PAC ID: 6507004157 Enrollment ID: I20220203001128 |
| Provider Name | John Kevin Painter |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598400350 PECOS PAC ID: 6507243961 Enrollment ID: I20220524003149 |
| Provider Name | Diana Marmolejos |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1467094821 PECOS PAC ID: 6204260979 Enrollment ID: I20230112001229 |
| Provider Name | Cherise Dailey |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1396445854 PECOS PAC ID: 6901271519 Enrollment ID: I20230413001496 |
| Provider Name | Brianna Lee Vanderpool |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598539157 PECOS PAC ID: 5799129326 Enrollment ID: I20240222000064 |
| Provider Name | Courtney Demaiya Saunders |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1881311306 PECOS PAC ID: 0042658015 Enrollment ID: I20240410000352 |
| Provider Name | Rebecca Lawrence |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1144248360 PECOS PAC ID: 4880691476 Enrollment ID: I20240724004648 |
| Provider Name | Jacqueline Griffin |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1114583630 PECOS PAC ID: 0244621340 Enrollment ID: I20240821003500 |
| Provider Name | Chacey Bryan |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1699228734 PECOS PAC ID: 9234425885 Enrollment ID: I20241009002580 |
| Provider Name | Samuel Archino |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1649005877 PECOS PAC ID: 6901338938 Enrollment ID: I20241016001018 |
| Provider Name | Deborah Sadek |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1790487577 PECOS PAC ID: 5193173342 Enrollment ID: I20250106003348 |
| Provider Name | Jared Daniel Edmonds |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1245040567 PECOS PAC ID: 3375064835 Enrollment ID: I20250313000151 |
| Provider Name | Chrystal Marie Johnson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1073359253 PECOS PAC ID: 8820510423 Enrollment ID: I20250324000697 |
| Provider Name | Maher Elharake |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1598296956 PECOS PAC ID: 4284024860 Enrollment ID: I20250801002453 |
| Provider Name | Patricia Amber Brothers |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1871149856 PECOS PAC ID: 7719319391 Enrollment ID: I20250829002164 |
| Provider Name | Aniekan Bassey Okon Akpan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1396618450 PECOS PAC ID: 7012403603 Enrollment ID: I20260102003616 |
| Provider Name | Joetta Tokpah Togba |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1982574406 PECOS PAC ID: 4587140611 Enrollment ID: I20260108002389 |
| Provider Name | Lauren Ashley Drapiza |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1316401243 PECOS PAC ID: 1355676214 Enrollment ID: I20260115000359 |
| Provider Name | Susan Greene |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1982631040 PECOS PAC ID: 8820044829 Enrollment ID: I20260223000148 |
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