=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700533890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIVOTAL HEALTH AND WELLNESS CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2022
-----------------------------------------------------
Last Update Date | 12/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 CROSS PARK DR STE A
-----------------------------------------------------
City | PEARL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39208-9016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-397-6731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4244
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39047-4244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | GRENISHA L YOUNG
-----------------------------------------------------
Credential | PMHNP-BC FNP-C
-----------------------------------------------------
Telephone | 601-397-6731
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------