Healthcare Provider Details

I. General information

NPI: 1194226225
Provider Name (Legal Business Name): DYNAMIC PAIN & WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2018
Last Update Date: 02/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4457 BAYOU BLVD
PENSACOLA FL
32503-2601
US

IV. Provider business mailing address

930 MAR WALT DRIVE UNIT C
FORT WALTON BEACH FL
32547
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax:
Mailing address:
  • Phone: 850-226-6801
  • Fax:

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