Provider Demographics
NPI:1619863982
Name:KONDO, SUSSIE AFI
Entity type:Individual
Prefix:
First Name:SUSSIE
Middle Name:AFI
Last Name:KONDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 GREEN FARMS RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1001
Mailing Address - Country:US
Mailing Address - Phone:508-579-1452
Mailing Address - Fax:508-579-1452
Practice Address - Street 1:25 GREEN FARMS RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1001
Practice Address - Country:US
Practice Address - Phone:508-579-1452
Practice Address - Fax:508-579-1452
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-14
Last Update Date:2025-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2025031005363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty