MEDICARE: REBECCA JANE DIVACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	1110084	TX

General Provider Information

NPI Number	:	1275025231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA JANE DIVACK

Provider Business Mailing Address
First Line	:	1430 W GRAND PKWY S
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-8204
Country	:	US
Telephone Number	:	832-844-1470
Fax Number	:	832-965-9490

Provider Business Practice Location Address
First Line	:	1430 W GRAND PKWY S
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-8204
Country	:	US
Telephone Number	:	832-844-1470
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2018
Last Update Date	:	12/05/2025

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Directions to “ REBECCA JANE DIVACK ” Practice Location

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