Healthcare Provider Details

I. General information

NPI: 1356206890
Provider Name (Legal Business Name): THE FAIRY TOX-MOTHER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 VISTA WAY SUITE A
OCEANSIDE CALIFORNIA
92056
UM

IV. Provider business mailing address

3913 CAMEO DR
OCEANSIDE CALIFORNIA
92056
UM

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EMELY MARIE BOLSTON
Title or Position: OWNER
Credential: NP
Phone: 442-202-4635