Provider Demographics
NPI:1952952798
Name:UPSHAW, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:UPSHAW
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:PO BOX 24844
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-0844
Mailing Address - Country:US
Mailing Address - Phone:937-974-6277
Mailing Address - Fax:
Practice Address - Street 1:6681 SPOKANE DR
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-2243
Practice Address - Country:US
Practice Address - Phone:937-974-6277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH145673164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse