Provider Demographics
NPI:1265186399
Name:HEWSTON, TABATHA
Entity type:Individual
Prefix:
First Name:TABATHA
Middle Name:
Last Name:HEWSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 CARRINGTON LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-4217
Mailing Address - Country:US
Mailing Address - Phone:850-341-0514
Mailing Address - Fax:850-679-4042
Practice Address - Street 1:2606 CARRINGTON LAKES BLVD
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-4217
Practice Address - Country:US
Practice Address - Phone:850-341-0514
Practice Address - Fax:850-679-4042
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005816900Medicaid