Healthcare Provider Details

I. General information

NPI: 1255346003
Provider Name (Legal Business Name): GENON MICHELLE WICINA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 SE SALERNO RD SUITE 116
STUART FL
34997-6572
US

IV. Provider business mailing address

PO BOX 417
STUART FL
34995-0417
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-5777
  • Fax:
Mailing address:
  • Phone: 772-223-5665
  • Fax: 772-223-5646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0074465
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: