Organization
DIVINITY PEDIATRIC CLINIC, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
REKITA D. MCCOY FNP (CEO)
(601) 345-4044
Entity
Organization
Contact information
Practice address
200 RIVERWIND DR STE 104, PEARL, MS 39208-5652
(601) 345-4044
(601) 510-9334
Mailing address
463 MAGNOLIA PL, BRANDON, MS 39042-8482
(601) 934-2603
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
—
—
363LP0200X
Pediatric Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1629741152
—
MS
Enumeration date
07/29/2021
Last updated
09/03/2022
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