Nicole Lynn Watson, CRNA

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

0024171495 Issued in VA

Practice address

12642 Chapel Rd
Clifton, VA 20124-1953

Phone

(703) 988-3984

Fax

(703) 988-7530

NPI assigned

Nov 1, 2013

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 5

Addresses

Other identifiers 3

Other names 1

• Nicole Lynn Willett Former name

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Revival Wellness & Ketamine

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Chantilly, VA
  • NPI 1093514655
  NPD Authorized official
• CML Solutions, LLC

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Ashburn, VA
  • NPI 1609616838
  NPD (past)

Medicare fee-for-service enrollment

Enrolled in VA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1383264000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1787097600000",
    "number": "1063841971",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12642 CHAPEL RD",
            "city": "CLIFTON",
            "state": "VA",
            "postal_code": "201241953",
            "telephone_number": "703-988-3984",
            "fax_number": "703-988-7530"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12642 CHAPEL RD",
            "city": "CLIFTON",
            "state": "VA",
            "postal_code": "201241953",
            "telephone_number": "703-988-3984",
            "fax_number": "703-988-7530"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "44355 Premier Plz Ste 210",
            "address_purpose": "LOCATION",
            "city": "Ashburn",
            "state": "VA",
            "postal_code": "201475050",
            "country_code": "US",
            "telephone_number": "703-857-2560",
            "fax_number": "703-988-7530",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WATSON",
        "first_name": "NICOLE",
        "middle_name": "LYNN",
        "credential": "CRNA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2013-11-01",
        "last_updated": "2026-08-19",
        "certification_date": "2026-08-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "VA",
            "license": "0024171495",
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "DC",
            "license": "RN1011818",
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "FL",
            "license": "RN9325226",
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "VA",
            "license": "0001219226",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "VA",
            "license": "0024171495",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1063841971",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "422488400",
            "state": "MD"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "049742400",
            "state": "DC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "NICOLE",
            "last_name": "WILLETT",
            "middle_name": "LYNN",
            "credential": "CRNA",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Teen Talk Counseling
• The Corvus Center for Mental Health Services
• Navjeet Ubee, DDS
• Jennifer Walker, LPC
• Suzan Joy Watkinson, CCLS
• Janet Ann Williams-Janas, CPNP
• Mary Colleen Wood, MPT
• Jennifer Youngen, PT

• All providers in Clifton, VA
• Psychiatric/Mental Health Nurse Practitioner in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 19, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.