Provider Demographics
NPI:1750368650
Name:LIGHT, MARIETTA FORMOSO (NP-C)
Entity type:Individual
Prefix:
First Name:MARIETTA
Middle Name:FORMOSO
Last Name:LIGHT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:782 MEDICAL CENTER DR E STE 212
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6889
Practice Address - Country:US
Practice Address - Phone:559-451-3676
Practice Address - Fax:559-451-3680
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6030363LF0000X, 363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA302503OtherREGISTERED NURSE LIC
CA6030OtherNURSE PRACTITIONER FURN