Healthcare Provider Details

I. General information

NPI: 1235845082
Provider Name (Legal Business Name): DIVINITY WELLNESS CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N DUNLEITH AVE
WINSTON SALEM NC
27101-3374
US

IV. Provider business mailing address

PO BOX 286
WALLBURG NC
27373-0286
US

V. Phone/Fax

Practice location:
  • Phone: 336-221-3454
  • Fax: 336-245-4601
Mailing address:
  • Phone: 336-221-3454
  • Fax: 336-245-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DEXTERIA REBECCA JENKINS
Title or Position: OWNER
Credential: AGNP-C
Phone: 336-225-1079