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General NPI Number Information
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NPI Number | 1619506557
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Entity Type | Individual
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Provider Name | KENETTE ST-GOURDIN MD
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Gender | Female
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Dates
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Enumeration Date | 04/03/2020
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 631 CAMPBELL HILL ST NW STE 200
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City | MARIETTA
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State | GA
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Zip | 30060-1390
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Country | US
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Telephone | 770-727-4130
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Fax | 770-800-1334
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Provider Business Mailing Address
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Address Line | 631 CAMPBELL HILL ST NW STE 200
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City | MARIETTA
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State | GA
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Zip | 30060-1390
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Country | US
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Telephone | 314-448-3791
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Fax | 636-996-7658
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | 2023049186
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 96398
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License Number State | GA
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