Provider Demographics
NPI:1447741350
Name:MOON SPOT WELLNESS CENTER PC
Entity Type:Organization
Organization Name:MOON SPOT WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADVANCED PRACTICE NURSE PRACTITIONE
Authorized Official - Prefix:DR
Authorized Official - First Name:MECHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PLASSE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PHD
Authorized Official - Phone:508-735-9406
Mailing Address - Street 1:1442 OLD PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-2139
Mailing Address - Country:US
Mailing Address - Phone:508-735-9406
Mailing Address - Fax:774-568-5605
Practice Address - Street 1:36 N BEDFORD ST STE 3
Practice Address - Street 2:
Practice Address - City:EAST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02333-1186
Practice Address - Country:US
Practice Address - Phone:508-735-9406
Practice Address - Fax:774-568-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA176838363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPN0618OtherBLUE CROSS
MA1854984Medicaid
MA176838OtherAPRN LICENSE