Provider Demographics
NPI:1124719547
Name:HEWETT, MAKAYLA O
Entity type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:O
Last Name:HEWETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAKAYLA
Other - Middle Name:O
Other - Last Name:GRISSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-750-4843
Practice Address - Street 1:28 SOUTHPOINTE DR
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-6238
Practice Address - Country:US
Practice Address - Phone:870-239-2244
Practice Address - Fax:870-236-1616
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR301382795Medicaid