Marietta Formoso Light, NP-C

Primary specialty

Obstetrics & Gynecology Nurse PractitionerTaxonomy code 363LX0001X

License

6030 Issued in CA

Practice address

782 Medical Center Dr E Ste 212
Clovis, CA 93611-6889

Phone

(559) 451-3676

Fax

(559) 451-3680

NPI assigned

Dec 30, 2005

Last updated

Oct 8, 2020By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Omni Women's Health Medical Group, Inc

  • Clinical Medical Laboratory
  • Fresno, CA
  • NPI 1891997813
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1135900800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1602115200000",
    "number": "1750368650",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2625 E DIVISADERO ST",
            "city": "FRESNO",
            "state": "CA",
            "postal_code": "937211431",
            "telephone_number": "559-443-2682",
            "fax_number": "559-443-2681"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "782 MEDICAL CENTER DR E STE 212",
            "city": "CLOVIS",
            "state": "CA",
            "postal_code": "936116889",
            "telephone_number": "559-451-3676",
            "fax_number": "559-451-3680"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "782 Medical Center Dr E # 212",
            "address_purpose": "LOCATION",
            "city": "Clovis",
            "state": "CA",
            "postal_code": "936116889",
            "country_code": "US",
            "telephone_number": "559-451-3676",
            "fax_number": "559-451-3680",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "LIGHT",
        "first_name": "MARIETTA",
        "middle_name": "FORMOSO",
        "credential": "NP-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-12-30",
        "last_updated": "2020-10-08",
        "certification_date": "2020-10-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "CA",
            "license": "6030",
            "primary": false
        },
        {
            "code": "363LW0102X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Women's Health",
            "state": "CA",
            "license": "6030",
            "primary": false
        },
        {
            "code": "363LX0001X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Obstetrics & Gynecology",
            "state": "CA",
            "license": "6030",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "REGISTERED NURSE LIC",
            "identifier": "302503",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NURSE PRACTITIONER FURN",
            "identifier": "6030",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Tyiesha Moha Lewis
• Perla Leyva
• Eric Chen Li, M.D.
• Li Li, M.D.
• Daniel Anthony Licona
• Andrew J Lilles, PT, DPT
• Joyce Lin
• Li T. Lin
• Rose Marie Ann Lindbeck, R. N.
• Lindsay Dietetic Services Incorporated

• Obstetrics & Gynecology Nurse Practitioner in Clovis, CA
• Providers in Clovis, CA by specialty
• Obstetrics & Gynecology Nurse Practitioner in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.