Provider Demographics
NPI:1063841971
Name:WATSON, NICOLE LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:WATSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:WILLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3100 SPRING FOREST RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-0705
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-776-3138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001219226163W00000X
FLRN9325226163W00000X
DCRN1011818163W00000X
VA0024171495367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063841971Medicaid
MD422488400Medicaid
DC049742400Medicaid
DC338363Y6DMedicare PIN
P01323958Medicare PIN