MEDICARE: THE FAIRY TOX-MOTHER INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner

General Provider Information

NPI Number	:	1356206890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE FAIRY TOX-MOTHER INC.

Provider Business Mailing Address
First Line	:	3913 CAMEO DR
Second Line	:
City	:	OCEANSIDE
State	:	CALIFORNIA
Zip	:	92056
Country	:	UM
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 VISTA WAY
Second Line	:	SUITE A
City	:	OCEANSIDE
State	:	CALIFORNIA
Zip	:	92056
Country	:	UM
Telephone Number	:
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EMELY MARIE BOLSTON
Credential	:	NP
Telephone Number	:	442-202-4635

Provider Enumeration Date	:	12/17/2025
Last Update Date	:	12/17/2025

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