# DIVINITY PEDIATRIC CLINIC, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1629741152
- **Authorized official:** REKITA D. MCCOY FNP (CEO)
- **Authorized official phone:** (601) 345-4044

## Contact information

- **Practice address:** 200 RIVERWIND DR STE 104, PEARL, MS 39208-5652
- **Practice address phone:** (601) 345-4044
- **Practice address fax:** (601) 510-9334
- **Mailing address:** 463 MAGNOLIA PL, BRANDON, MS 39042-8482
- **Mailing address phone:** (601) 934-2603

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QP2300X | Primary Care Clinic/Center | — | NULL | — |
| 363LP0200X | Pediatric Nurse Practitioner | — | NULL | Yes |
| 363LP0200X | Pediatric Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 07/29/2021
- **Last updated:** 09/03/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1629741152 | — | MS |