Healthcare Provider Details

I. General information

NPI: 1902288962
Provider Name (Legal Business Name): LAKISHA JEANETTE BURTON WILLIS MBA, M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 TOWN CENTER WAY
HAMPTON VA
23666-1999
US

IV. Provider business mailing address

4188 OLD DOMINION DR
WEST BLOOMFIELD MI
48323-2659
US

V. Phone/Fax

Practice location:
  • Phone: 757-251-2170
  • Fax:
Mailing address:
  • Phone: 313-701-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301188560
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101273401
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: