Healthcare Provider Details

I. General information

NPI: 1912833385
Provider Name (Legal Business Name): LISETTE WILLIS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 MEDICAL CENTER DR
SAN BERNARDINO CA
92411-1217
US

IV. Provider business mailing address

5374 NOVARA AVE
FONTANA CA
92336-0246
US

V. Phone/Fax

Practice location:
  • Phone: 909-887-6333
  • Fax:
Mailing address:
  • Phone: 909-414-4211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95039779
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: