Provider Demographics
NPI:1235845082
Name:DIVINITY WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:DIVINITY WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEXTERIA
Authorized Official - Middle Name:REBECCA
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:336-225-1079
Mailing Address - Street 1:PO BOX 286
Mailing Address - Street 2:
Mailing Address - City:WALLBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27373-0286
Mailing Address - Country:US
Mailing Address - Phone:336-225-1079
Mailing Address - Fax:877-243-1084
Practice Address - Street 1:620 N DUNLEITH AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3374
Practice Address - Country:US
Practice Address - Phone:336-278-1318
Practice Address - Fax:844-453-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No251J00000XAgenciesNursing CareGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No347C00000XTransportation ServicesPrivate Vehicle
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty