Provider Demographics
NPI:1619506557
Name:ST-GOURDIN, KENETTE (MD)
Entity type:Individual
Prefix:
First Name:KENETTE
Middle Name:
Last Name:ST-GOURDIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 CAMPBELL HILL ST NW STE 200
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1390
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:636-996-7658
Practice Address - Street 1:631 CAMPBELL HILL ST NW STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1390
Practice Address - Country:US
Practice Address - Phone:770-727-4130
Practice Address - Fax:770-800-1334
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023049186208M00000X
390200000X
GA96398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program