Healthcare Provider Details

I. General information

NPI: 1003734500
Provider Name (Legal Business Name): MAISEY JOY BOLDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2252 BOULDER CREEK ST
CHULA VISTA CA
91915-2155
US

IV. Provider business mailing address

2252 BOULDER CREEK ST
CHULA VISTA CA
91915-2155
US

V. Phone/Fax

Practice location:
  • Phone: 619-622-7779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE195475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: