Provider Demographics
NPI:1396567301
Name:DIVINITY HEALTHCARE INC
Entity type:Organization
Organization Name:DIVINITY HEALTHCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRINITY
Authorized Official - Middle Name:SHARDA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-848-3656
Mailing Address - Street 1:99 WINCHESTER DR UNIT K
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-2083
Mailing Address - Country:US
Mailing Address - Phone:662-848-3656
Mailing Address - Fax:
Practice Address - Street 1:99 WINCHESTER DR UNIT K
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-2083
Practice Address - Country:US
Practice Address - Phone:662-848-3656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-30
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care