Healthcare Provider Details

I. General information

NPI: 1104730381
Provider Name (Legal Business Name): HENRY WILDER GENELUS PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14520 NW 5TH AVE
MIAMI FL
33168-4106
US

IV. Provider business mailing address

14520 NW 5TH AVE
MIAMI FL
33168-4106
US

V. Phone/Fax

Practice location:
  • Phone: 786-709-3926
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number409301
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: