Healthcare Provider Details

I. General information

NPI: 1366420853
Provider Name (Legal Business Name): SUPAKUNYA EDMONSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS ENTERPRISE MEDICAL DEPT
NORFOLK VA
23551-0001
US

IV. Provider business mailing address

1714 POMPEY ST
VIRGINIA BEACH VA
23464-6514
US

V. Phone/Fax

Practice location:
  • Phone: 757-444-8632
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2022046492
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0102201767
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: