Provider Demographics
NPI:1164016978
Name:UPSHAW, KHRISHUNDA (TRICHOLOGIST/HHP)
Entity Type:Individual
Prefix:DR
First Name:KHRISHUNDA
Middle Name:
Last Name:UPSHAW
Suffix:
Gender:F
Credentials:TRICHOLOGIST/HHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 GARONA DR
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6647
Mailing Address - Country:US
Mailing Address - Phone:310-754-5297
Mailing Address - Fax:
Practice Address - Street 1:2700 TEMPLE AVE STE D
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2280
Practice Address - Country:US
Practice Address - Phone:310-754-5297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA228944003174400000X, 335E00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No174400000XOther Service ProvidersSpecialist
No335E00000XSuppliersProsthetic/Orthotic Supplier