MEDICARE: REVIVE 3.2 WELLNESS NURSING PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1295693588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE 3.2 WELLNESS NURSING PC

Provider Business Mailing Address
First Line	:	10328 RESEDA BLVD
Second Line	:
City	:	NORTHRIDGE
State	:	CA
Zip	:	91326-3433
Country	:	US
Telephone Number	:	818-634-0082
Fax Number	:

Provider Business Practice Location Address
First Line	:	10328 RESEDA BLVD
Second Line	:
City	:	NORTHRIDGE
State	:	CA
Zip	:	91326-3433
Country	:	US
Telephone Number	:	818-634-0082
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER/CEO
Name	:	MS. DIANNE KRISTINE PALASIO
Credential	:	NP
Telephone Number	:	818-634-0082

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	01/14/2026

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