Provider Demographics
NPI:1467762062
Name:RUNGE, MARILEE KRISTINEA FAIRCLOTH (MSN)
Entity Type:Individual
Prefix:
First Name:MARILEE
Middle Name:KRISTINEA FAIRCLOTH
Last Name:RUNGE
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:MARILEE
Other - Middle Name:KRISTENEA
Other - Last Name:FLAIRCLOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN
Mailing Address - Street 1:2085 FRONTIS PLAZA
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 SILAS CREEK PARKWAY
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3099
Practice Address - Country:US
Practice Address - Phone:336-718-8278
Practice Address - Fax:336-718-9271
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC152495367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered