Healthcare Provider Details

I. General information

NPI: 1184419228
Provider Name (Legal Business Name): BOREALIS HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 S POKEGAMA AVE STE A
GRAND RAPIDS MN
55744-3934
US

IV. Provider business mailing address

813 S POKEGAMA AVE STE A
GRAND RAPIDS MN
55744-3934
US

V. Phone/Fax

Practice location:
  • Phone: 218-297-1900
  • Fax:
Mailing address:
  • Phone: 218-297-1900
  • Fax: 218-203-4788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIE JON BATA
Title or Position: OWNER
Credential:
Phone: 218-297-1900