Healthcare Provider Details

I. General information

NPI: 1922938174
Provider Name (Legal Business Name): DYNAMIC PAIN & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 N 12TH AVE
PENSACOLA FL
32504-8918
US

IV. Provider business mailing address

930 MAR WALT DRIVE STE C
FORT WALTON BEACH FL
32547-6706
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax: 877-413-5104
Mailing address:
  • Phone: 850-226-6801
  • Fax: 877-413-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: TRISTA ELLIOTT
Title or Position: CREDENTIALING
Credential:
Phone: 850-226-6801