Healthcare Provider Details

I. General information

NPI: 1699262980
Provider Name (Legal Business Name): DYNAMIC PAIN & WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6044 DOCTORS PARK
MILTON FL
32570-5072
US

IV. Provider business mailing address

600 HOSPITAL DR
CRESTVIEW FL
32539-7356
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-2607
  • Fax: 877-413-5104
Mailing address:
  • Phone: 850-331-2930
  • Fax: 877-413-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH BAILEY
Title or Position: CREDENTIALING
Credential:
Phone: 850-331-2930