Healthcare Provider Details

I. General information

NPI: 1063841971
Provider Name (Legal Business Name): NICOLE LYNN WATSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE LYNN WILLETT CRNA

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12642 CHAPEL RD
CLIFTON VA
20124-1953
US

IV. Provider business mailing address

12642 CHAPEL RD
CLIFTON VA
20124-1953
US

V. Phone/Fax

Practice location:
  • Phone: 703-988-3984
  • Fax: 703-988-7530
Mailing address:
  • Phone: 703-988-3984
  • Fax: 703-988-7530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024171495
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1011818
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9325226
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001219226
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024171495
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: