1467762062 NPI number — MARILEE KRISTINEA FAIRCLOTH RUNGE MSN

Table of content: MARILEE KRISTINEA FAIRCLOTH RUNGE MSN (NPI 1467762062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467762062 NPI number — MARILEE KRISTINEA FAIRCLOTH RUNGE MSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUNGE
Provider First Name:
MARILEE
Provider Middle Name:
KRISTINEA FAIRCLOTH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLAIRCLOTH
Provider Other First Name:
MARILEE
Provider Other Middle Name:
KRISTENEA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467762062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2085 FRONTIS PLAZA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON-SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-5614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 SILAS CREEK PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON-SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-3099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-718-8278
Provider Business Practice Location Address Fax Number:
336-718-9271
Provider Enumeration Date:
10/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  152495 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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