Provider Demographics
NPI:1740613215
Name:LAROCCA, NICOLE K (RN, CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:LAROCCA
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:2013-08-19
Last Update Date:2014-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001220203163W00000X
OH388481163W00000X
MI4704297425163W00000X
VA0024171480367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD422346200Medicaid
DC075835800Medicaid
VA1740613215Medicaid
MD422346200Medicaid