Provider Demographics
NPI:1689044182
Name:MOONSTONE MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:MOONSTONE MEDICAL GROUP, PLLC
Other - Org Name:SHELLY LAFRANCE, FNP, PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFRANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MN, FNP-BC
Authorized Official - Phone:360-326-3171
Mailing Address - Street 1:9320 NE VANCOUVER MALL DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-8203
Mailing Address - Country:US
Mailing Address - Phone:360-326-3171
Mailing Address - Fax:
Practice Address - Street 1:9320 NE VANCOUVER MALL DR
Practice Address - Street 2:SUITE 103
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-8203
Practice Address - Country:US
Practice Address - Phone:360-326-3171
Practice Address - Fax:360-326-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-28
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007234363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9652660Medicaid
WA9652660Medicaid