{
"Npi": {
"NPI": "1619506557",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "ST-GOURDIN",
"FirstName": "KENETTE",
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": "MD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "631 CAMPBELL HILL ST NW STE 200",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MARIETTA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30060-1390",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "314-448-3791",
"MailingAddressFaxNumber": "636-996-7658",
"FirstLinePracticeLocationAddress": "631 CAMPBELL HILL ST NW STE 200",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MARIETTA",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30060-1390",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "770-727-4130",
"PracticeLocationAddressFaxNumber": "770-800-1334",
"EnumerationDate": "04/03/2020",
"LastUpdateDate": "12/04/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "208M00000X",
"TaxonomyName": "Hospitalist Physician",
"LicenseNumber": "2023049186",
"LicenseNumberStateCode": "MO",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "390200000X",
"TaxonomyName": "Student in an Organized Health Care Education/Training Program",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207R00000X",
"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": "96398",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}