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General NPI Number Information
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NPI Number | 1912833385
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Entity Type | Individual
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Provider Name | LISETTE WILLIS PMHNP
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Gender | Female
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Dates
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Enumeration Date | 06/22/2026
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Last Update Date | 06/22/2026
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Provider Practice Location Address
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Address Line | 1805 MEDICAL CENTER DR
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City | SAN BERNARDINO
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State | CA
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Zip | 92411-1217
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Country | US
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Telephone | 909-887-6333
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Fax |
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Provider Business Mailing Address
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Address Line | 5374 NOVARA AVE
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City | FONTANA
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State | CA
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Zip | 92336-0246
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Country | US
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Telephone | 909-414-4211
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 95039779
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License Number State | CA
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