Provider Demographics
NPI:1629741152
Name:DIVINITY PEDIATRIC CLINIC, PLLC
Entity Type:Organization
Organization Name:DIVINITY PEDIATRIC CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REKITA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-345-4044
Mailing Address - Street 1:463 MAGNOLIA PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-8482
Mailing Address - Country:US
Mailing Address - Phone:601-934-2603
Mailing Address - Fax:
Practice Address - Street 1:200 RIVERWIND DR STE 104
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-5652
Practice Address - Country:US
Practice Address - Phone:601-345-4044
Practice Address - Fax:601-510-9334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-29
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1629741152Medicaid