Provider Demographics
NPI:1285623728
Name:ST PIERRE-MACKOUL, ANNETTE M (MD)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:M
Last Name:ST PIERRE-MACKOUL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8530 GRANITE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4102
Mailing Address - Country:US
Mailing Address - Phone:239-415-1131
Mailing Address - Fax:239-415-1136
Practice Address - Street 1:8530 GRANITE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4102
Practice Address - Country:US
Practice Address - Phone:239-415-1131
Practice Address - Fax:239-415-1136
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67399208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000697700Medicaid
FL024174700Medicaid
FL377085100Medicaid
FL003463600Medicaid