Healthcare Provider Details

I. General information

NPI: 1154241701
Provider Name (Legal Business Name): KENNETH LAURO SUBALA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12041 TEJON ST
WESTMINSTER CO
80234-2314
US

IV. Provider business mailing address

804 NUCLA ST
AURORA CO
80011-4341
US

V. Phone/Fax

Practice location:
  • Phone: 303-993-7356
  • Fax:
Mailing address:
  • Phone: 720-244-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.1002184-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: