Provider Demographics
NPI:1639540982
Name:LO, MARIE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:LO
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 1:5133 PARK HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5816
Mailing Address - Country:US
Mailing Address - Phone:201-238-3796
Mailing Address - Fax:
Practice Address - Street 1:5133 PARK HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5816
Practice Address - Country:US
Practice Address - Phone:201-238-3796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2025-09-13
Deactivation Date:2025-08-27
Deactivation Code:
Reactivation Date:2025-09-11
Provider Licenses
StateLicense IDTaxonomies
MDR247223363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health